Reduced dispensing of prescribed antibiotics during the Covid-19 pandemic has not increased severe complications from common infections

Background

Sweden has seen an accelerated decline in the number of dispensed antibiotic prescriptions from an already low level during the Covid-19 pandemic. This prompted us to explore whether the decrease in antibiotic prescriptions has reached a critically low level and resulted in an increase in treatment of severe complications from common infections. The aim was to study if the accelerated decrease in antibiotic sales has led to an increase in complications in outpatients with common infections.

Method

A population-based nationwide registry study based on the Swedish Prescribed Drug Register and the National Patient Register.

Results

The total number of dispensed antibiotic prescriptions decreased by 17% during 2020 compared to 2019. The decrease was most pronounced in younger age groups and for antibiotics targeting respiratory tract infections. The number of hospital admissions and visits to open specialist care due to pneumonia or complications related to otitis, tonsillitis, or sinusitis decreased by 4–44%. Prescriptions and numbers of visits or admissions due to urinary tract infections and skin infections remained largely unchanged compared to previous years.

Conclusion

No increase in complications due to common bacterial infections could be detected despite an unprecedented decline in dispensed antibiotic prescriptions in outpatient care in 2020. The decrease in dispensed antibiotic prescriptions from pharmacies was probably primarily related to a general decrease in the incidence of respiratory infections due to the recommendations and restrictions implemented to mitigate the Covid-19 pandemic in Sweden. This in return led to fewer doctors’ visits and consequently to fewer occasions to prescribe antibiotics, be they warranted or not.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-12692-1.

Analysis of regional differences in the amount of hypnotic and anxiolytic prescriptions in Japan using nationwide claims data

BACKGROUND

In Japan, there has been no investigation of regional differences in the number or amount of prescriptions of anxiolytics or hypnotics. Attributes related to the high amount of prescriptions for these drugs are unknown. We investigated recent trends and regional differences in the amount of prescriptions of hypnotics and anxiolytics in Japan and identified factors associated with these regional differences.

METHODS

The National Database of Health Insurance Claims and Specific Health Checkups of Japan (NDB) Open data from 2015 to 2018 were used. We calculated diazepam-equivalent doses (mg) for each drug and the total amount of prescriptions per capita for hypnotics and anxiolytics by sex and age. In addition, we calculated the standardized claim ratio (SCR) of the amount of prescriptions by prefecture. We investigated factors associated with regional differences in the SCRs of hypnotics and anxiolytics using the prefectures' medical, socioeconomic, and physical characteristics by an ecological study using a linear mixed-effects model.

RESULTS

The amount of prescriptions of hypnotics and anxiolytics, specifically, the amount of prescriptions of benzodiazepine receptor agonists (BZRAs), decreased in many of the adult age groups from 2015 to 2018. The regression analysis revealed that the number of medical clinics per capita, the number of public assistance recipients per capita, the proportion of persons whose HbA1c ≥ 6.5%, and the proportion of persons whose BMI ≥25 kg/m2 were positively and significantly associated with the SCR of hypnosis. In contrast, the number of public assistance recipients per capita and the proportion of persons whose BMI ≥25 kg/m2 were positively and significantly associated with the SCR of anxiolytics.

CONCLUSIONS

Factors associated with prescription amount of hypnotics and anxiolytics were revealed in this study, and a further study is needed for investigating causal relationships between the prescriptions amount and the associated factors using individual data.

Implementation of clinical audit to improve adherence to guideline-recommended therapy in acute coronary syndrome

BACKGROUND

Despite global consensus on the management of acute coronary syndrome (ACS), implementation of strategies to improve adherence of guideline-directed medical therapy (GDMT) remains sub-optimal, especially in developing countries. Thus, we aimed to assess the effect of clinical pharmacist-led clinical audit to improve the compliance of discharge prescriptions in patients admitted with ACS. It is a prospective clinical audit of ACS patients which was carried out for 12 months. The discharge prescriptions were audited by clinical pharmacists for the appropriateness in the usage of statins, dual antiplatelet therapy (DAPT), beta-blockers, and angiotensin-converting enzyme inhibitors (ACE-I)/angiotensin receptor blocker (ARB). A feedback report was presented every month to the cardiologists involved in the patient care, and the trend in the adherence to GDMT was analyzed over 12 months.

RESULTS

The discharge prescriptions of 1072 ACS patients were audited for the justifiable and non-justifiable omissions of mandated drugs. The first-month audit revealed unreasonable omissions of DAPT, statin, ACE-I/ARB, and beta-blockers in 1%, 0%, 14%, and 11% respectively, which reduced to nil by the end of the 11th month of the audit-feedback program. This improvement remained unchanged until the end of the 12th month.

CONCLUSIONS

The study revealed that periodic clinical audit significantly improves adherence to GDMT in patients admitted with ACS.

Using Belgian pharmacy dispensing data to assess antibiotic use for children in ambulatory care

BACKGROUND

The desired effect of antibiotics is compromised by the rapid escalation of antimicrobial resistance. Children are particularly at high-risk for unnecessary antibiotic prescribing, which is owing to clinicians' diagnostic uncertainty combined with parents' concerns and expectations. Recent Belgian data on ambulatory antibiotic prescribing practices for children are currently lacking. Therefore, we aim to analyse different aspects of antibiotic prescriptions for children in ambulatory care.

METHODS

Pharmacy dispensing data on antibiotics for systematic use referring from 2010 to 2019 were retrieved from Farmanet, a database of pharmaceutical dispensations in community pharmacies. Population data were obtained from the Belgian statistical office (Statbel). Descriptive statistics were performed in Microsoft Excel. The Mann-Kendall test for trend analysis and the seasplot function for seasonality testing were conducted in R.

RESULTS

The past decade, paediatric antibiotic use and expenditures have relatively decreased in Belgian ambulatory care with 35.5% and 44.3%, respectively. The highest volumes of antibiotics for children are prescribed by GPs working in Walloon region and rural areas, to younger children, and during winter. The most prescribed class of antibiotics for children are the penicillins and the biggest relative reduction in number of packages is seen for the sulfonamides and trimethoprim and quinolone antibacterials.

CONCLUSIONS

Paediatric antibiotic use has decreased in Belgian ambulatory care. Further initiatives are needed to promote prudent antibiotic prescribing in ambulatory care.

Differences in Hypertension Medication Prescribing for Black Americans and Their Association with Hypertension Outcomes

BACKGROUND

National guidelines recommend different pharmacologic management of hypertension (HTN) without comorbidities for Black/African Americans (BAA) compared with non-BAA. We sought to 1) identify if these recommendations have influenced prescription patterns in BAA and 2) identify the differences in uncontrolled HTN in BAA on different antihypertensive medications.

METHODS

We constructed a linked retrospective observational cohort using 2 years of electronic health records data, comprising of patients aged 18 to 85 with HTN on 1- or 2-drug regimens, including angiotensin-converting enzyme inhibitors (ACE), angiotensin receptor blockers (ARB), thiazide diuretics, or calcium channel blockers (CCB). We examined prescribing differences and HTN control in BAA versus non-BAA.

RESULTS

Among 10,875 patients identified, 20.6% were identified as BAA. 46.4% of BAA had uncontrolled HTN (≥140/90 mmHg) compared with 39.0% of non-BAA (P < .001). 61.8% of BAA were treated with 1-drug compared with 68.4% of non-BAA. Of BAA on monotherapy: 41.3% were on thiazide, 40.1% on CCB, and 18.6% on ACE/ARB. Of non-BAA on monotherapy, 27.7% were on thiazide, 30.1% were on CCB, and 42.3% were on ACE/ARB. Of BAA patients on 1 drug, 45.2% had uncontrolled HTN compared with 38.0% of non-BAA (P < .001). Of BAA on 2 drugs, 48.2% had uncontrolled HTN compared with 41.1% non-BAA (P < .001). For each drug regimen, there was more variation in HTN control within each group than between BAA and non-BAA.

CONCLUSIONS

Providers seem to be following race-based guidelines for HTN, yet HTN control for BAA remains worse than non-BAA. An individualized approach to HTN therapy for all patients may be more important than race-based guidelines.

Korean physician prescription patterns for home oxygen therapy in chronic obstructive pulmonary disease patients

BACKGROUND/AIMS

Hypoxemia in chronic obstructive pulmonary disease (COPD) leads to reduced ability to exercise, decreased quality of life, and, eventually, increased mortality. Home oxygen therapy in patients with severe COPD reduces distress symptoms and mortality rates. However, there have been few studies on physicians' prescription behavior toward home oxygen therapy. Therefore, we investigated the respiratory specialists' perspective on home oxygen therapy.

METHODS

In this cross-sectional, study, a questionnaire was completed by 30 pulmonary specialists who worked in tertiary hospitals and prescribed home oxygen therapy. The questionnaire consisted of 28 items, including 15 items on oxygen prescription for outpatients, four for inpatients, and nine on service improvement.

RESULTS

All physicians were prescribing less than 2 L/min of oxygen for either 24 (n = 10, 33.3%) or 15 hours (n = 9, 30.3%). All (n = 30) used pulse oximetry, 26 (86.7%) analyzed arterial blood gas. Thirteen physicians had imposed restrictions and recommended oxygen use only during exercise or sleep. Sixteen (53.3%) physicians were educating their patients about home oxygen therapy. Furthermore, physicians prescribed home oxygen to patients that did not fit the typical criteria for long-term oxygen therapy, with 30 prescribing it for acute relief and 17 for patients with borderline hypoxemia.

CONCLUSION

This study identified the prescription pattern of home oxygen therapy in Korea. Respiratory physicians prescribe home oxygen therapy to hypoxemic COPD patients for at least 15 hours/day, and at a rate of less than 2 L/min. More research is needed to provide evidence for establishing policies on oxygen therapy in COPD patients.

Prospective Prescription Review System Promotes Safe Use of Analgesics, Improves Clinical Outcomes, and Saves Medical Costs in Surgical Patients: Insights from Nanjing Drum Tower Hospital

Introduction

The rate of awareness of prospective prescription review for inpatient prescriptions remains low, and no study has evaluated prospective prescription review systems among hospitalized patients. In this study we evaluate the effect of a prospective prescription review system on the use of analgesics, clinical outcomes, and medical costs in hospitalized patients who underwent surgery.

Methods

A single-center, real-world study was conducted retrospectively at Drum Tower Hospital, Nanjing, China. Patient data were extracted from the medical records, before (June 2016–May 2017) and after (June 2018–May 2019) prescription review system implementation. The primary outcome was proportion of prescriptions of analgesics with potential risks. The secondary outcomes included prescription of opioids or non-opioids, usage of medications to manage analgesics-related adverse events, clinical outcomes, and medical costs. Propensity score matching was used to balance the cohort of patients before and after implementation of the prescription review system.

Results

A total of 28,150 inpatients were included for study analysis. After implementation of the prescription review system, the proportion of prescriptions of analgesics with potential risk was significantly reduced (6.3% vs 26.1%, P < 0.05). A significant decrease was observed in the proportion of patients prescribed opioids (24.3% vs 27.5%, P < 0.001) and tramadol (4.7% vs 12.1%, P < 0.001). There was a significant decrease in prescription of antiemetics (21.8% vs 34.1%, P < 0.001) and cathartics (38.4% vs 50.6%, P < 0.001) which were used in the management of opioid-related adverse events. There was a decreased length of stay in hospital [median (Q1, Q3) 10 (6, 17) vs 11 (7, 18), P < 0.01)] with similar readmission rates within 30 days post discharge (1.0% vs 0.8%, P = 0.099).

Conclusions

The introduction of the prescription review system was associated with safer prescribing, including a reduction in prescriptions of analgesics with potential risk and necessity of medication to manage analgesics-related adverse events, which resulted in better clinical outcomes and cost saving.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12325-021-01935-z.

Mortality by opioid poisoning in children and teenagers and opioid prescriptions

Background

No comparisons between mortality from opioids in children and teenagers and opioid prescription patterns have been made in England.

Aim

To investigate if an association exists between mortality rates from opioid poisoning in persons aged 19 years old and under and community opioid prescription in England.

Methods

A retrospective analysis was undertaken for 2016 to 2019, comparing community opioid prescriptions and mortality rates from opioid poisoning.

Results

The number of opioid prescriptions decreased over the study period (− 2.4%, p < 0.001). Most deaths due to opioid poisoning in children and teenagers were seen in those under one year old and those aged between 15 and 19 years old (Kruskal-Wallis: p = 0.12; Dunn’s test: p = 0.01). Deaths in all age ranges did not change significantly (Poisson Regression Analysis: p > 0.05).

Conclusion

Despite the reduction in community opioid prescriptions, there was no decrease in the number of deaths in children and teenagers due to opioid poisoning.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12887-021-03061-9.

Association Between Statewide Opioid Prescribing Interventions and Opioid Prescribing Patterns in North Carolina, 2006-2018

OBJECTIVE

To examine the impact of three sequential statewide policy and legislative interventions on opioid prescribing practices among privately insured individuals in North Carolina.

METHODS

An interrupted time series approach was used to examine level and trajectory changes of new and prevalent opioid prescription rates, days' supply, and daily morphine milligram equivalents before and after implementation of a 1) prescription drug monitoring program, 2) state medical board initiative, and 3) legislative action. Analyses were conducted using individual-level claims data from a large private health insurance provider serving North Carolina residents, ages 18-64 years, from January 2006 to August 2018.

RESULTS

Rates of new and prevalent prescription opioid patients were relatively unaffected by the prescription monitoring program but sharply declined in the months immediately following both medical board (-3.7 new and -19.3 prevalent patients per 10,000 person months) and legislative (-14.1 new and -26.7 prevalent patients) actions. Among all opioid prescriptions, days' supply steadily increased on average over the study period but declined after legislative action (-1.5 days' supply per year).

CONCLUSIONS

The voluntary prescription drug monitoring program launched in 2010 only marginally affected opioid prescribing patterns on its own, but its redeployment as an investigative and clinical tool in multifaceted public policy approaches by the state medical board and legislature later in the decade plausibly contributed to notable declines in prescription rates and days' supply. This study lends new emphasis to the importance of enforcement mechanisms for state and national policies seeking to reverse this critical public health crisis.

Are Amphetamines Associated with Adverse Cardiovascular Events Among Elderly Individuals?

BACKGROUND

Prescription amphetamines are the most common pharmacological treatment for attention deficit hyperactivity disorder (ADHD) and use among older age groups is increasing. The purpose of this study is to assess the risk of adverse cardiovascular events among individuals older than 65 years.

METHODS

We conducted a retrospective matched cohort study using TriNetX database with propensity score matching (PSM) to assess the odds of a cardiovascular event among individuals with ADHD exposed to amphetamine compared with individuals with ADHD who were not exposed to this medication. During the index period of January 1, 2018, through December 31, 2020, 13,233 individuals older than 65 years (mean age = 69 years) met the study criteria.

RESULTS

The cohort exposed to amphetamine had increased blood pressure and increased odds of cardiovascular events (odds ratio [OR], 6.16; absolute risk difference = 3.31%) compared with the control group.

CONCLUSIONS

Amphetamines have clear safety data in younger age cohorts; however, this safety data may not generalize to older populations. Additional research is warranted to clarify further exposure and subpopulation-level risk factors associated with adverse cardiovascular events among older patients.

Nudge me: tailoring text messages for prescription adherence through N-of-1 interviews

Almost 50% of patients with cardiovascular diseases face challenges in taking medications and increased morbidity and mortality. Text messaging may impact medication refill behavior and can be delivered at scale to patients by texting mobile phones. To obtain feedback from persons with chronic conditions on the design of interactive text messages and determine language of message for making messages that can motivate patients to refill medications on time. We purposively sampled 35 English and Spanish speaking patients with at least one chronic condition from three large healthcare delivery systems to participate in N-of-1 video-based synchronous interviews. Research assistants shared ideas for theory-informed text messages with content intended to persuade patients to refill their medication. We transcribed recorded interviews and conducted a content analysis to identify strategies to employ generating a dynamic interactive text message library intended to increase medication refill. Those interviewed were of diverse age and race/ethnicity and typical of persons with multiple chronic conditions. Several participants emphasized that personally tailored and positively framed messages would be more persuasive than generic and/or negative messages. Some patients appreciated humor and messages that could evoke a sense of social support from their providers and rejected the use of emojis. Messages to remind patients to refill medications may facilitate improvements in adherence, which in turn can improve chronic care. Designing messages that are persuasive and can prompt action is feasible and should be considered given the ease with which such messages can be delivered automatically at scale.

Over-the-Counter Medication Prescribing in a Pediatric Emergency Department: Health Records Review

OBJECTIVE

The purpose of this project was to describe patterns in over-the-counter medication prescribing for nonacute patients with Medicaid in a pediatric emergency department. Differences were also tested in visit time and charges between patients with and without over-the-counter medication prescriptions.

METHODS

Retrospective chart review of children with Missouri Medicaid presenting to a single site between January 1, 2018 and December 31, 2018. Low-acuity patients with common diagnoses were included. Over-the-counter medications prescribed, the cost of prescriptions, the time spent in the emergency department, provider care time, patient age, and the month of visit were extracted. Data were analyzed with descriptive statistics and t tests.

RESULTS

Approximately 37% of children were prescribed over-the-counter medications, most commonly antipyretics. When comparing visits in which an over-the-counter medication was prescribed to visits without an over-the-counter medication prescription, we found no significant difference in the associated charges, total time in the department, and provider care time.

CONCLUSION

Over-the-counter medications were prescribed for more than one-third of children cared for in the pediatric emergency department for low-acuity presentations. These visits may represent a substantial area for Medicaid access barriers, system redesign, and cost savings.

Opioid Prescribing After Implementation of Single Click Access to a State Prescription Drug Monitoring Program Database in a Health System's Electronic Health Record

OBJECTIVES

To determine the effect of one-click integration of a state's prescription drug monitoring program (PDMP) on the number of PDMP searches and opioid prescriptions, stratified by specialty.

METHODS

Our large health system worked with the state department of public health to integrate the PDMP with the electronic health record (EHR), which enabled providers to query the data with a single click inside the EHR environment. We evaluated Schedule II or III opioid prescriptions reported to the Massachusetts PDMP 6 months before (November 15, 2017-May 15, 2018) and 6 months after (May 16, 2018, to November 16, 2018) integration. Search counts, prescriptions, patients, morphine milligram equivalents, as well as prescriber specialty were compared.

RESULTS

There were 3,185 unique prescribers with a record of a Schedule II and/or III opioid prescription in both study periods that met inclusion criteria. After integration, the number of PDMP searches increased from 208,684 in the pre-integration phase to 298,478 searches in the post-integration phase (+43.0%). The number of opioid prescriptions dispensed decreased by 4.8%, the number of patients receiving a prescription decreased by 5.1%, and the mean morphine milligram equivalents (MMEs) per prescriber decreased by 5.4%. There were some notable specialty-specific differences in these measures.

CONCLUSIONS

Integration of the PDMP into the EHR markedly increased the number of searches but was associated with modest decreases in opioids prescribed and patients receiving a prescription. Single click EHR integration of the PDMP, if implemented broadly, may be a way for states to significantly increase PDMP utilization.

Helpers help people with intellectual and developmental disabilities and hypertension to understand their condition and the need to adhere to anti-hypertensive medication

BACKGROUND

Recent evidence suggests that many adults with intellectual and developmental disabilities (IDD) do not adequately manage hypertension (HTN) medication. Known risk factors for insufficient prescription filling include age, residential placement, and lack of caregiver support. This is a first report of a randomized intervention trial designed to analyze the relationship of a brief educational intervention with increased knowledge about HTN and improvement in prescription filling for anti-hypertensive medication.

OBJECTIVE/HYPOTHESIS

The objective was to test whether an educational flyer and regular messages about HTN and the importance of refilling medication would improve scores on knowledge surveys. Participants were Medicaid members with HTN and IDD (Member) or caregivers (Helpers) who chose to participate on behalf of a Member.

METHODS

Recruitment letters explained that either the Member or their Helper could participate (not both). Participants were randomly assigned to the Case or Comparison group, and both were comprised of Members and Helpers. Only Case participants received a flyer and monthly HTN education messages for one year, but all participants completed knowledge surveys at baseline, six, and 12 months. Linear regression and log-binomial models were used to compare responses between groups.

RESULTS

Case Helpers had statistically significant improvements on HTN knowledge from baseline through the first year, compared to Comparison Members and Comparison Helpers. Regardless of group assignment, Helpers scored better on surveys than did Members.

CONCLUSIONS

This study suggests that it is beneficial to explicitly include Helpers in health care instruction and in management of chronic disease for adults with IDD.

Analysis of the regional difference in the number of multi-drug prescriptions and its predictors in Japan, 2015-2018

Objective

Polypharmacy and multi-drug prescription are major public health problems in Japan, but only a few studies have investigated the regional differences. By revealing regional differences in the multi-drug prescriptions, we can infer regions with high rates of multimorbidity or inappropriate prescribing. This study revealed regional differences in multi-drug prescriptions (the number of simultaneous prescriptions of seven or more internal medicines) and investigated the factors affecting the difference using the National Database of Health Insurance Claims and Specific Health Checkups of Japan data.

Results

The standardized claim ratio (SCR) of the number of multi-drug prescriptions, which corrected the difference in sex and age distribution of prefectures, varied depending on prefectures. A panel data analysis investigating the association between the SCR and explanatory variables (Medical institutions, socioeconomic factors, and physical characteristics of people in prefectures) revealed that the number of public assistance recipients per 1,000 persons was positively and significantly associated with the SCR (Standardized partial regression coefficient = 0.244, p-value = 0.038). In conclusion, regional differences in the number of the multi-drug prescriptions were revealed in Japan, suggesting that public assistance recipients tend to experience multi-drug prescriptions.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13104-021-05787-2.

Cross-sectional analysis of coding, patient characteristics, consultation frequency and pharmacological treatment of adults with severe mental disorders in Irish general practice

Background

General practitioners are the gatekeepers of Irish healthcare and they offer continuity of care to patients. Irish general practice is therefore considered appropriate for preventing, diagnosing and managing most mental health problems.

Aims

This study sought to establish the coding frequency, consultation frequency, patient characteristics and pharmacological treatment of patients with severe mental disorders (SMDs) in Irish general practice.

Methods

A cross-sectional design was used. A finder tool embedded in the practice software assisted general practitioners (GPs) coding adult patients with SMDs. Eleven practices uploaded anonymous data on 2,203 patients. Variables analysed included disease code, consultations, prescriptions, sex, patient status and age.

Results

Overall, 2.9% (n = 2,337) of patients had ever been coded with a SMD, 2.4% (n = 1,964) coded with depressive disorder ever and 0.26% (n = 209) and 0.3% (n = 233) with bipolar disorder and schizophrenia, respectively. Overall, 68.0% (n = 1,336) of patients with depressive disorder were female, and 74.0% (n = 171) of patients with schizophrenia were public patients. The median consultation rate in the previous 3 years was highest for schizophrenia patients at 24.5 visits.

Conclusions

Coding of SMDs in Irish general practice appears incomplete. Patients with SMDs have high consultation rates. Patients with depressive disorder are more likely to be female and public patients. This research suggests that the improvement of coding in Irish general practice is the first practical step required to detecting prevalence rates.

Supplementary Information

The online version contains supplementary material available at 10.1007/s11845-021-02747-4.

Diabetes, hypertension and dyslipidemia medication prescribing in Qatari primary care settings: a retrospective analysis of electronic medical records

Background

Globally, non-communicable diseases (NCDs) are recognised as a leading cause of morbidity and mortality. Medications and medicines optimisation play an important role in the management of modifiable physiological risk factors and NCDs. The importance of lifestyle interventions in prevention of modifiable risk factors is also well established. The aim of this paper was to describe the quantity of type 2 diabetes mellitus (T2DM), hypertension and dyslipidaemia prescribing in Qatari primary care settings. Its findings will provide necessary information to inform pharmaceutical policy and practice.

Methods

The study was undertaken in Qatar’s publicly funded primary health care centres. Data sources for this study comprised electronic medical records. The Anatomical Therapeutic Chemical (ATC) drug classification system was used to classify the medications prescribed. The number and proportion of medications by age, sex, nationality and diagnosis (T2DM, hypertension and dyslipidaemia) were reported.

Results

A total 81,569 individuals were included (18–29 years 2.4%; 30–39 years 11.7%; 40–49 years 25.4%; 50–59 years 31.9% and ≥ 60 years 28.6%). 55.6% participants were male. On average 10.2 medications were prescribed per person and 2.3 medications were included in each prescription. T2DM medications were most prescribed (N = 361,87780,799; 43.2%) followed by hypertension (N = 303,086; 36.2%) and dyslipidaemia (N = 172,163; 20.5%). Of the total medications prescribed, 72% (N = 605,488) were prescribed in individuals aged 50 years and above. Men were prescribed 62% (N = 515,043) medications while women were prescribed 38% (N = 322,083) medications. Southern Asians (N = 330,338; 39%) were prescribed most medication followed by Qataris (N = 181,328; 22%) and Northern African (N = 145,577; 17%).

Conclusions

In Qatar’s primary care settings, average medications prescribed per patients were found to be higher compared to other populations. While medications were actively prescribed for the 3 conditions, the study found variations by medication type, age, gender and nationality. Rational guidelines for the utilisation of medications need to be established with the support of real-world evidence.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40545-021-00353-4.

Using point-of-care diagnostic testing for improved antibiotic prescription: an economic model

BACKGROUND

Antibiotics have been overprescribed to treat infectious diseases and have generated antimicrobial resistances that reduce their effectiveness. Following the rationale behind the new paradigm of personalized medicine, point-of-care diagnostic testing (POCT) has been proposed to improve the quality of antibiotic prescription with the aim of reducing antimicrobial resistances.

METHODS

In order to understand whether this recommendation is valid, we create a theoretical economic model to determine under which conditions the expected benefits of using POCT to guide antibiotic prescription are greater than for empiric prescription, where we define the expected benefits as the difference between the economic value of health and the costs of the treatment. We consider the interaction of a group of physicians who express differing levels of uncertainty when prescribing with a firm selling a diagnostic device, and analyse the firm's pricing policy and the physicians' prescribing decisions. We allow the physicians to internalize the external costs of antimicrobial resistances.

RESULTS

We find that the use of POCT reduces the number of antibiotic prescriptions. The reduction in antibiotic prescriptions is higher when physicians internalise the costs of antimicrobial resistances. Physicians with relatively high levels of uncertainty use POCT as they are uncertain about the right treatment for a large proportion of patients. Physicians with low levels of uncertainty prefer to prescribe empirically. The segmentation in the population of physicians regarding the uptake of POCT depends on the distribution of levels of uncertainty across physicians. For each test, the firm charges the marginal production costs of the inputs needed to administer the test, and makes its profit from the sales of the testing devices.

CONCLUSIONS

From a theoretical perspective, our findings corroborate the fact that POCT improve the quality of antibiotic prescription and reduce the number of prescriptions. Nevertheless, their use is not always recommended as empiric therapy may be preferred when uncertainty is low.

Association of physician experience with a higher prescription rate of anti-influenza agents in low-risk patients

During the influenza season, most patients suspected of having influenza undergo rapid influenza diagnostic tests (RIDTs) in Japan despite their low sensitivity. However, the physician's actual rationale for prescribing antivirals, besides the results of RIDTs, remains poorly understood. Our study sought to identify the role of clinical information and physicians' experience in the initiation of anti-influenza agents. We retrospectively reviewed 380 patients who underwent RIDTs at the emergency department of our hospital from September 2018 to May 2019. Data regarding sex, age, etc., which could affect the decision of prescribing antivirals, were extracted from medical records. We performed logistic regression analysis to analyze the concurrent effect of potentially relevant clinical factors, results of RIDTs, and the physician's status on antiviral prescription. Multivariable analysis revealed that a positive RIDT had the largest effect on antiviral prescription, followed by physician status, high regional influenza activity, and patients' presentation within 12 h of symptom onset. Patient's age, comorbidities, and presentation after 48 h of symptom onset were not associated with antiviral treatment. Physicians with more years of experience were significantly more likely to prescribe antivirals for patients with low risk of complications. Our findings revealed the physicians' rationale for initiating antiviral treatment and the discrepancy with guideline indications of antivirals, which is the patient's age and comorbidities. Physicians, especially those with more than 3 years of experience, frequently prescribed antivirals for patients with low risk of complications; thus, educational interventions against this population could be useful to improve this situation.

A Survey of Systemic Antibiotic Prescription Patterns Amongst Iraqi Dentists

OBJECTIVES

The misuse of antibiotic prescriptions is a common behavior amongst dentists worldwide. Over-prescription of these agents is associated with multiple adverse effects and risk of developing bacterial resistance. The aim of this study was to assess systemic antibiotic prescription patterns amongst dentists in Iraq.

METHODS

A questionnaire-based survey was conducted in dental centres distributed in 12 Iraqi governates. The questionnaire was composed of two main sections: The first was dedicated to collecting demographic and work-related information, and the second section included questions seeking details about antibiotic prescriptions for different oral and dental conditions.

RESULTS

A total of 481 valid questionnaires were considered in the final analysis. The numbers of correct and incorrect patterns of prescribing antibiotics for different dental/oral conditions were almost equal (49.6% and 50.4%, respectively). Amongst independent variables investigated, qualification of the dentist and work domain were found to have significant associations with correct prescribing patterns (odds ratio, 1.166 and 1.197, respectively). The majority of dentists preferred amoxicillin as the first-choice antibiotic, followed by "Augmentin" (43.7% and 35.5%, respectively), whilst clarithromycin was the lowest on the list. Azithromycin was the most recommended antibiotic (55.9%) in cases of allergy to penicillin.

CONCLUSIONS

In general, antibiotics are prescribed for recommended conditions, but the prescription for nonrecommended conditions was also evident amongst Iraqi dentists. Correct pattern of antibiotic prescribing was significantly associated with specialists and those working in the academic field. Additionally, amoxicillin and its derivatives are the most preferred drugs.

Prevalence of polypharmacy and associated adverse health outcomes in adult patients with chronic kidney disease: protocol for a systematic review and meta-analysis

BACKGROUND

Polypharmacy, often defined as the concomitant use of ≥ 5 medications, has been identified as a significant global public health threat. Aging and multimorbidity are key drivers of polypharmacy and have been linked to a broad range of adverse health outcomes and mortality. Patients with chronic kidney disease (CKD) are particularly at high risk of polypharmacy and use of potentially inappropriate medications given the numerous risk factors and complications associated with CKD. The aim of this systematic review will be to assess the prevalence of polypharmacy among adult patients with CKD, and the potential association between polypharmacy and adverse health outcomes within this population.

METHODS/DESIGN

We will search empirical databases such as MEDLINE, Embase, Cochrane Library, CINAHL, Web of Science, and PsycINFO and grey literature from inception onwards (with no language restrictions) for observational studies (e.g., cross-sectional or cohort studies) reporting the prevalence of polypharmacy in adult patients with CKD (all stages including dialysis). Two reviewers will independently screen all citations, full-text articles, and extract data. Potential conflicts will be resolved through discussion. The study methodological quality will be appraised using an appropriate tool. The primary outcome will be the prevalence of polypharmacy. Secondary outcomes will include any adverse health outcomes (e.g., worsening kidney function) in association with polypharmacy. If appropriate, we will conduct random effects meta-analysis of observational data to summarize the pooled prevalence of polypharmacy and the associations between polypharmacy and adverse outcomes. Statistical heterogeneity will be estimated using Cochran's Q and I2 index. Additional analyses will be conducted to explore the potential sources of heterogeneity (e.g., sex, kidney replacement therapy, multimorbidity).

DISCUSSION

Given that polypharmacy is a major and a growing public health issue, our findings will highlight the prevalence of polypharmacy, hazards associated with it, and medication thresholds associated with adverse outcomes in patients with CKD. Our study will also draw attention to the prognostic importance of improving medication practices as a key priority area to help minimize the use of inappropriate medications in patients with CKD.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO registration number: [ CRD42020206514 ].

E-prescribing and access to prescription medicines during lockdown: experience of patients in Aotearoa/New Zealand

Background

Health services internationally have been compelled to change their methods of service delivery in response to the global COVID-19 pandemic, to mitigate the spread of infection amongst health professionals and patients. In Aotearoa/New Zealand, widespread electronic delivery of prescriptions (e-prescribing) was enabled. The aim of the research was to explore patients’ experiences of how lockdown, changes to prescribing and the interface between general practices and community pharmacy affected access to prescription medications.

Method

The research employed a mixed-method approach. This included an online survey (n = 1,010) and in-depth interviews with a subset of survey respondents (n = 38) during the first COVID-19 lockdown (March–May 2020). Respondents were recruited through a snowballing approach, starting with social media and email list contacts of the research team. In keeping with the approach, descriptive statistics of survey data and thematic analysis of qualitative interview and open-ended questions in survey data were combined.

Results

For most respondents who received a prescription during lockdown, this was sent directly to the pharmacy. Most people picked up their medication from the pharmacy; home delivery of medication was rare (4%). Survey and interview respondents wanted e-prescribing to continue post-lockdown and described where things worked well and where they encountered delays in the process of acquiring prescription medication.

Conclusions

E-prescribing has the potential to improve access to prescription medication and is convenient for patients. The increase in e-prescribing during lockdown highlighted how the system could be improved, through better feedback about errors, more consistency across practices and pharmacies, more proactive communication with patients, and equitable prescribing costs.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12875-021-01490-0.

An introduction to network analysis for studies of medication use

BACKGROUND

Network Analysis (NA) is a method that has been used in various disciplines such as Social sciences and Ecology for decades. So far, NA has not been used extensively in studies of medication use. Only a handful of papers have used NA in Drug Prescription Networks (DPN). We provide an introduction to NA terminology alongside a guide to creating and extracting results from the medication networks.

OBJECTIVE

To introduce the readers to NA as a tool to study medication use by demonstrating how to apply different NA measures on 3 generated medication networks.

METHODS

We used the Norwegian Prescription Database (NorPD) to create a network that describes the co-medication in elderly persons in Norway on January 1, 2013. We used the Norwegian Electronic Prescription Support System (FEST) to create another network of severe drug-drug interactions (DDIs). Lastly, we created a network combining the two networks to show the actual use of drugs with severe DDIs. We used these networks to elucidate how to apply and interpret different network measures in medication networks.

RESULTS

Interactive network graphs are made available online, Stata and R syntaxes are provided. Various useful network measures for medication networks were applied such as network topological features, modularity analysis and centrality measures. Edge lists data used to generate the networks are openly available for readers in an open data repository to explore and use.

CONCLUSION

We believe that NA can be a useful tool in medication use studies. We have provided information and hopefully inspiration for other researchers to use NA in their own projects. While network analyses are useful for exploring and discovering structures in medication use studies, it also has limitations. It can be challenging to interpret and it is not suitable for hypothesis testing.

Variations in Postoperative Opioid Prescription Practices and Impact on Refill Prescriptions Following Lumbar Spine Surgery

OBJECTIVE

Understanding postsurgical prescribing patterns and their impact on persistent opioid use is important for establishing reasonable opioid prescribing protocols. We aimed to determine national variation in postoperative opioid prescription practices following elective lumbar spine surgery and their impact on short-term refill prescriptions.

METHODS

The OptumLabs Data Warehouse was queried from 2016 to 2017 for adults undergoing anterior lumbar fusion, posterior lumbar fusion, circumferential lumbar fusion, and lumbar decompression/discectomy for degenerative spine disease. Discharge opioid prescription fills were obtained and converted to morphine milligram equivalents (MMEs). Age- and sex-adjusted MMEs and frequency of discharge prescriptions >200 MMEs were determined for each U.S. census division and procedure type.

RESULTS

The study included 43,572 patients with 37,894 postdischarge opioid prescription fills. There was wide variation in mean filled MMEs across all census divisions (anterior lumbar fusion: 774-1147 MMEs; posterior lumbar fusion: 717-1280 MMEs; circumferential lumbar fusion: 817-1271 MMEs; lumbar decompression/discectomy: 619-787 MMEs). A significant proportion of cases were found to have filled discharge prescriptions >200 MMEs (posterior lumbar fusion: 78.6%-95%; anterior lumbar fusion: 87.5%-95.6%; circumferential lumbar fusion: 81.4%-96.5%; lumbar decompression/discectomy: 80.5%-91%). Multivariable logistic regression showed that female sex and inpatient surgery were associated with a top-quartile discharge prescription and a short-term second opioid prescription fill, while the opposite was noted for elderly and opioid-naïve patients (all P ≤ 0.05). Prescriptions with long-acting opioids were associated with higher odds of a second opioid prescription fill (reference: nontramadol short-acting opioid).

CONCLUSIONS

In analysis of filled opioid prescriptions, we observed a significant proportion of prescriptions >200 MMEs and wide regional variation in postdischarge opioid prescribing patterns following elective lumbar spine surgery.

Opioid Prescribing to Medicare Part D Enrollees, 2013-2017: Shifting Responsibility to Pain Management Providers

OBJECTIVE

To examine opioid prescribing frequency and trends to Medicare Part D enrollees from 2013 to 2017 by medical specialty and provider type.

METHODS

We conducted a retrospective, cross-sectional, specialty- and provider-level analysis of Medicare Part D prescriber data for opioid claims from 2013 to 2017. We analyzed opioid claims and prescribing trends for specialties accounting for ≥1% of all opioid claims.

RESULTS

From 2013 to 2017, pain management providers increased Medicare Part D opioid claims by 27.3% to 1,140 mean claims per provider in 2017; physical medicine and rehabilitation providers increased opioid claims 16.9% to 511 mean claims per provider in 2017. Every other medical specialty decreased opioid claims over this period, with emergency medicine (-19.9%) and orthopedic surgery (-16.0%) dropping opioid claims more than any specialty. Physicians overall decreased opioid claims per provider by -5.2%. Meanwhile, opioid claims among both dentists (+5.6%) and nonphysician providers (+10.2%) increased during this period.

CONCLUSIONS

From 2013 to 2017, pain management and PMR increased opioid claims to Medicare Part D enrollees, whereas physicians in every other specialty decreased opioid prescribing. Dentists and nonphysician providers also increased opioid prescribing. Overall, opioid claims to Medicare Part D enrollees decreased and continue to drop at faster rates.