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Cornwall N, Woodcock C, Ashworth J, Harrisson SA, Dikomitis L, White S, Helliwell T, Hodgson E, Knaggs R, Pincus T, Santer M, Mallen CD, Jinks C. Acceptability of a proposed practice pharmacist-led review for opioid-treated patients with persistent pain: A qualitative study to inform intervention development. Br J Pain 2024; 18:274-291. [PMID: 38751561 PMCID: PMC11092934 DOI: 10.1177/20494637231221688] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/18/2024] Open
Abstract
Introduction Regular review of patients prescribed opioids for persistent non-cancer pain (PCNP) is recommended but not routinely undertaken. The PROMPPT (Proactive clinical Review of patients taking Opioid Medicines long-term for persistent Pain led by clinical Pharmacists in primary care Teams) research programme aims to develop and test a pharmacist-led pain review (PROMPPT) to reduce inappropriate opioid use for persistent pain in primary care. This study explored the acceptability of the proposed PROMPPT review to inform early intervention development. Methods Interviews (n = 15) and an online discussion forum (n = 31) with patients prescribed opioids for PCNP and interviews with pharmacists (n = 13), explored acceptability of a proposed PROMPPT review. A prototype PROMPPT review was then tested and refined through 3 iterative cycles of in-practice testing (IPT) (n = 3 practices, n = 3 practice pharmacists, n = 13 patients). Drawing on the Theoretical Framework of Acceptability (TFA), a framework was generated (including a priori TFA constructs) allowing for deductive and inductive thematic analysis to identify aspects of prospective and experienced acceptability. Results Patients felt uncertain about practice pharmacists delivering the proposed PROMPPT review leading to development of content for the invitation letter for IPT (introducing the pharmacist and outlining the aim of the review). After IPT, patients felt that pharmacists were suited to the role as they were knowledgeable and qualified. Pharmacists felt that the proposed reviews would be challenging. Although challenges were experienced during delivery of PROMPPT reviews, pharmacists found that they became easier to deliver with time, practise and experience. Recommendations for optimisations after IPT included development of the training to include examples of challenging consultations. Conclusions Uptake of new healthcare interventions is influenced by perceptions of acceptability. Exploring prospective and experienced acceptability at multiple time points during early intervention development, led to mini-optimisations of the prototype PROMPPT review ahead of a non-randomised feasibility study.
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Affiliation(s)
| | | | - Julie Ashworth
- School of Medicine, Keele University, Keele, UK
- Midlands Partnership University NHS Foundation Trust, Haywood Hospital, Stoke on Trent, UK
| | - Sarah A Harrisson
- School of Medicine, Keele University, Keele, UK
- Midlands Partnership University NHS Foundation Trust, Haywood Hospital, Stoke on Trent, UK
| | - Lisa Dikomitis
- Centre for Health Services Studies and Kent and Medway Medical School, University of Kent, Canterbury, UK
| | - Simon White
- School of Pharmacy and Bioengineering, Keele University, Keele, Staffordshire, UK
| | - Toby Helliwell
- School of Medicine, Keele University, Keele, UK
- Midlands Partnership University NHS Foundation Trust, Haywood Hospital, Stoke on Trent, UK
| | | | - Roger Knaggs
- Division of Pharmacy Practice and Policy, School of Pharmacy, University of Nottingham, Nottingham, UK
- Pain Centre Versus Arthritis, Clinical Sciences Building, City Hospital, Nottingham, UK
- UK & Primary Integrated Community Services, Nottingham, UK
| | - Tamar Pincus
- Department of Psychology, University of Southampton, Southampton, UK
| | - Miriam Santer
- Primary Care Research Centre, University of Southampton, Southampton, UK
| | - Christian D Mallen
- School of Medicine, Keele University, Keele, UK
- Midlands Partnership University NHS Foundation Trust, Haywood Hospital, Stoke on Trent, UK
| | - Clare Jinks
- School of Medicine, Keele University, Keele, UK
| | - on behalf of the PROMPPT team
- School of Medicine, Keele University, Keele, UK
- Midlands Partnership University NHS Foundation Trust, Haywood Hospital, Stoke on Trent, UK
- Centre for Health Services Studies and Kent and Medway Medical School, University of Kent, Canterbury, UK
- School of Pharmacy and Bioengineering, Keele University, Keele, Staffordshire, UK
- Leek Health Centre, Leek, UK
- Division of Pharmacy Practice and Policy, School of Pharmacy, University of Nottingham, Nottingham, UK
- Pain Centre Versus Arthritis, Clinical Sciences Building, City Hospital, Nottingham, UK
- UK & Primary Integrated Community Services, Nottingham, UK
- Department of Psychology, University of Southampton, Southampton, UK
- Primary Care Research Centre, University of Southampton, Southampton, UK
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2
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Scott IC, Whittle R, Bailey J, Twohig H, Hider SL, Mallen CD, Muller S, Jordan KP. Analgesic prescribing in patients with inflammatory arthritis in England: observational studies in the Clinical Practice Research Datalink. Rheumatology (Oxford) 2024; 63:1672-1681. [PMID: 37822018 PMCID: PMC11147543 DOI: 10.1093/rheumatology/kead463] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2023] [Accepted: 08/18/2023] [Indexed: 10/13/2023] Open
Abstract
OBJECTIVES Despite little evidence that analgesics are effective in inflammatory arthritis (IA), studies report substantial opioid prescribing. The extent this applies to other analgesics is uncertain. We undertook a comprehensive evaluation of analgesic prescribing in patients with IA in the Clinical Practice Research Datalink Aurum to evaluate this. METHODS From 2004 to 2020, cross-sectional analyses evaluated analgesic prescription annual prevalence in RA, PsA and axial spondyloarthritis (axSpA), stratified by age, sex, ethnicity, deprivation and geography. Joinpoint regression evaluated temporal prescribing trends. Cohort studies determined prognostic factors at diagnosis for chronic analgesic prescriptions using Cox proportional hazards models. RESULTS Analgesic prescribing declined over time but remained common: 2004 and 2020 IA prescription prevalence was 84.2/100 person-years (PY) (95% CI 83.9, 84.5) and 64.5/100 PY (64.2, 64.8), respectively. In 2004, NSAIDs were most prescribed (56.1/100 PY; 55.8, 56.5), falling over time. Opioids were most prescribed in 2020 (39.0/100 PY; 38.7, 39.2). Gabapentinoid prescribing increased: 2004 prevalence 1.1/100 PY (1.0, 1.2); 2020 prevalence 9.9/100 PY (9.7, 10.0). Most opioid prescriptions were chronic (2020 prevalence 23.4/100 PY [23.2, 23.6]). Non-NSAID analgesic prescribing was commoner in RA, older people, females and deprived areas/northern England. Conversely, NSAID prescribing was commoner in axSpA/males, varying little by deprivation/geography. Peri-diagnosis was high-risk for starting chronic opioid/NSAID prescriptions. Prognostic factors for chronic opioid/gabapentinoid and NSAID prescriptions differed, with NSAIDs having no consistently significant association with deprivation (unlike opioids/gabapentinoids). CONCLUSION IA analgesic prescribing of all classes is widespread. This is neither evidence-based nor in line with guidelines. Peri-diagnosis is an opportune moment to reduce chronic analgesic prescribing.
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Affiliation(s)
- Ian C Scott
- Primary Care Centre Versus Arthritis, School of Medicine, Keele University, Keele, UK
- Haywood Academic Rheumatology Centre, Haywood Hospital, Midlands Partnership NHS Foundation Trust, High Lane, Burslem, Staffordshire, UK
| | - Rebecca Whittle
- Primary Care Centre Versus Arthritis, School of Medicine, Keele University, Keele, UK
| | - James Bailey
- Primary Care Centre Versus Arthritis, School of Medicine, Keele University, Keele, UK
| | - Helen Twohig
- Primary Care Centre Versus Arthritis, School of Medicine, Keele University, Keele, UK
| | - Samantha L Hider
- Primary Care Centre Versus Arthritis, School of Medicine, Keele University, Keele, UK
- Haywood Academic Rheumatology Centre, Haywood Hospital, Midlands Partnership NHS Foundation Trust, High Lane, Burslem, Staffordshire, UK
| | - Christian D Mallen
- Primary Care Centre Versus Arthritis, School of Medicine, Keele University, Keele, UK
- Haywood Academic Rheumatology Centre, Haywood Hospital, Midlands Partnership NHS Foundation Trust, High Lane, Burslem, Staffordshire, UK
| | - Sara Muller
- Primary Care Centre Versus Arthritis, School of Medicine, Keele University, Keele, UK
| | - Kelvin P Jordan
- Primary Care Centre Versus Arthritis, School of Medicine, Keele University, Keele, UK
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3
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Welsh VK, Mason KJ, Bailey J, Bajpai R, Jordan KP, Mallen CD, Burton C. Trends in consultations and prescribing for rheumatic and musculoskeletal diseases: an electronic primary care records study. Br J Gen Pract 2023; 73:e858-e866. [PMID: 37722859 PMCID: PMC10523337 DOI: 10.3399/bjgp.2022.0648] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Accepted: 05/15/2023] [Indexed: 09/20/2023] Open
Abstract
BACKGROUND Rheumatic and musculoskeletal diseases (RMDs) are common and generally managed in primary care through supported self-care, physiotherapy, analgesia, and specialist referral where indicated. The COVID-19 pandemic led to abrupt changes in primary care delivery, including moves to remote consulting, pauses on group-based self-care, and restricted referrals. AIM To describe how patterns of UK primary healthcare consultations and analgesic prescribing relating to RMDs changed during the COVID-19 pandemic. DESIGN AND SETTING Observational study using routinely collected national primary care electronic health record data from the Clinical Practice Research Datalink between 1 April 2017 and 1 October 2021. METHOD RMD and analgesic SNOMED-CT codes were derived through consensus and published work. Prevalent and incident RMD-related consultations were determined, and RMD consultations matched to prevalent and incident analgesia prescriptions. Joinpoint regression was used to describe trends over time. RESULTS Prevalent and incident RMD consultations steadily increased until March 2020 when a substantial drop occurred as pandemic- related restrictions were introduced; levels had not recovered to pre-pandemic highs by October 2021. While incident and prevalent analgesic prescribing also reduced around March 2020, the proportion of patients with an RMD consultation prescribed any analgesic increased from 27.72% in February 2020 to 38.15% in April 2020, with increases across all analgesic groups. A higher proportion of strong opioid prescriptions was seen in the most deprived areas. CONCLUSION Pandemic-associated restrictions led to fewer primary care consultations and relative increases in analgesic prescribing, including strong opioids, for RMDs in the UK. Policymakers must consider the impact of these changes in future healthcare resource planning.
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Affiliation(s)
- Victoria K Welsh
- Centre for Musculoskeletal Health Research, School of Medicine, Keele University, Keele
| | - Kayleigh J Mason
- Centre for Musculoskeletal Health Research, School of Medicine, Keele University, Keele
| | - James Bailey
- Centre for Musculoskeletal Health Research, School of Medicine, Keele University, Keele
| | - Ram Bajpai
- Centre for Musculoskeletal Health Research, School of Medicine, Keele University, Keele
| | - Kelvin P Jordan
- Centre for Musculoskeletal Health Research, School of Medicine, Keele University, Keele
| | - Christian D Mallen
- Centre for Musculoskeletal Health Research, School of Medicine, Keele University, Keele
| | - Claire Burton
- Centre for Musculoskeletal Health Research, School of Medicine, Keele University, Keele
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The Effect of Ginger and Its Sub-Components on Pain. PLANTS 2022; 11:plants11172296. [PMID: 36079679 PMCID: PMC9460519 DOI: 10.3390/plants11172296] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Revised: 08/27/2022] [Accepted: 08/31/2022] [Indexed: 11/16/2022]
Abstract
Zingiber officinale Roscoe (ginger) has long been used as an herbal medicine to treat various diseases, and its main sub-components, [6]-gingerol and [6]-shogaol, were also reported to have anti-inflammatory, anti-oxidant, and anti-tumor effects. However, their effects on various types of pain and their underlying mechanisms of action have not been clearly analyzed and understood yet. Thus, in this review, by analyzing 16 studies that used Z. officinale, [6]-gingerol, and [6]-shogaol on mechanical, spontaneous and thermal pain, their effects and mechanisms of action have been analyzed. Pain was induced by either nerve injury or chemical injections in rodents. Nine studies analyzed the analgesic effect of Z. officinale, and four and three studies focused on [6]-gingerol and [6]-shogaol, respectively. Seven papers have demonstrated the underlying mechanism of action of their analgesic effects. Studies have focused on the spinal cord and one on the dorsal root ganglion (DRG) neurons. Involvement and change in the function of serotonergic receptors (5-HT1A, B, D, and 5A), transient receptor potential vanilloid 1 (TRPV1), N-methyl-D-aspartate (NMDA) receptors, phosphorylated extracellular signal-regulated kinase 1/2 (pERK1/2), histone deacetylase 1 (HDAC1), voltage-gated sodium channel 1.8 (Nav1.8), substance P (SP), and sciatic nerve’s morphology have been observed.
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Perception of the Regulatory Change for Zolpidem Prescription by French General Practitioners and Its Relation to Prescription Behavior. J Clin Med 2022; 11:jcm11082176. [PMID: 35456269 PMCID: PMC9032177 DOI: 10.3390/jcm11082176] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Revised: 04/01/2022] [Accepted: 04/11/2022] [Indexed: 02/05/2023] Open
Abstract
Background: To “limit the risk of abuse and misuse” and “encourage correct usage”, the French drug regulatory authority stated that—from April 2017—zolpidem prescription must be performed on a secured prescription pad. This national study aims to evaluate the perception of general practitioners (GPs) towards this new regulation and its link with prescription strategies. Methods: We conducted structured interviews of GPs. Data were collected about GPs’ perception of the measure and therapeutic strategies towards zolpidem. The primary outcome was the description of the GPs’ strategy of prescription, based on the perception towards the new regulation for zolpidem. Results: For 206 GPs, the new regulation was mainly perceived as helpful (61%) and as a difficulty (55%). Other perceptions were the awareness of the risks of zolpidem (18%), awareness of the risks of hypnotics (13%), and nothing changed (5%). Four clusters of GPs were identified. In the clusters with the perception as a difficulty (only or associated with helpful), the GPs who applied the strategy “no modification” for >50% of their patients were more frequently compared to awareness and helpful only clusters (60.8%; 42.9%; 20.4%; 26.7%) (p < 0.001). Conclusions: We highlighted an association between the perception of the new regulation of zolpidem prescription by GPs and a strategy of prescription.
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6
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Scott IC, Bailey J, White C, Mallen CD, Muller S. Analgesia Prescribing in Patients with Inflammatory Arthritis in England: An Observational Study Using Electronic Healthcare Record Data. Rheumatology (Oxford) 2021; 61:3201-3211. [PMID: 34849617 PMCID: PMC9348777 DOI: 10.1093/rheumatology/keab870] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Revised: 11/10/2021] [Indexed: 11/13/2022] Open
Abstract
Objectives International data suggest inflammatory arthritis (IA) pain management frequently involves opioid prescribing, despite little evidence of efficacy, and potential harms. We evaluated analgesic prescribing in English National Health Service-managed patients with IA. Methods Repeated cross-sectional analyses in the Consultations in Primary Care Archive (primary care consultation and prescription data in nine general practices from 2000 to 2015) evaluated the annual prevalence of analgesic prescriptions in: (i) IA cases (RA, PsA or axial spondyloarthritis [SpA]), and (ii) up to five age-, sex- and practice-matched controls. Analgesic prescriptions were classified into basic, opioids, gabapentinoids and oral NSAIDs, and sub-classified into chronic and intermittent (≥3 and 1–2 prescriptions per calendar year, respectively). Results In 2000, there were 594 cases and 2652 controls, rising to 1080 cases and 4703 controls in 2015. In all years, most (65.3–78.5%) cases received analgesics, compared with fewer (37.5–41.1%) controls. Opioid prescribing in cases fell between 2000 and 2015 but remained common with 45.4% (95% CI: 42.4%, 48.4%) and 32.9% (95% CI: 29.8%, 36.0%) receiving at least 1 and ≥3 opioid prescriptions, respectively, in 2015. Gabapentinoid prescription prevalence in cases increased from 0% in 2000 to 9.5% (95% CI: 7.9%, 11.4%) in 2015, and oral NSAID prescription prevalence fell from 53.7% (95% CI: 49.6%, 57.8%) in 2000 to 25.0% (95% CI: 22.4%, 27.7%) in 2015. Across years, analgesic prescribing was commoner in RA than PsA/axial SpA, and 1.7–2.0 times higher in cases than controls. Conclusions Analgesic prescribing in IA is common. This is at variance with existing evidence of analgesic efficacy and risks, and guidelines. Interventions are needed to improve analgesic prescribing in this population.
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Affiliation(s)
- Ian C Scott
- Primary Care Centre Versus Arthritis, School of Medicine, Keele University, Keele, UK.,Haywood Academic Rheumatology Centre, Haywood Hospital, Midlands Partnership NHS Foundation Trust, High Lane, Burslem, Staffordshire, UK
| | - James Bailey
- Primary Care Centre Versus Arthritis, School of Medicine, Keele University, Keele, UK
| | - Chris White
- Primary Care Centre Versus Arthritis, School of Medicine, Keele University, Keele, UK.,Haywood Academic Rheumatology Centre, Haywood Hospital, Midlands Partnership NHS Foundation Trust, High Lane, Burslem, Staffordshire, UK
| | - Christian D Mallen
- Primary Care Centre Versus Arthritis, School of Medicine, Keele University, Keele, UK.,Haywood Academic Rheumatology Centre, Haywood Hospital, Midlands Partnership NHS Foundation Trust, High Lane, Burslem, Staffordshire, UK
| | - Sara Muller
- Primary Care Centre Versus Arthritis, School of Medicine, Keele University, Keele, UK
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De Zarate MO, Mentzakis E, Fraser SD, Roderick P, Rutter P, Ornaghi C. Price versus clinical guidelines in primary care statin prescribing: a retrospective cohort study and cost simulation model. J R Soc Med 2021; 115:100-111. [PMID: 34793261 PMCID: PMC8981530 DOI: 10.1177/01410768211051713] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
OBJECTIVE To investigate the relative impact of generic entry and National Institute for Health and Care Excellence clinical guidelines on prescribing using statins as an exemplar. DESIGN Retrospective analysis of statin prescribing in primary care and cost simulation model. SETTING Royal College of General Practitioners Research and Surveillance Centre (RCGP R&SC) database and Prescription Cost Analysis (PCA) database. PARTICIPANTS New patients prescribed statins for the first time between July 2003 and September 2018. RESULTS General trends of statin' prescriptions were largely driven by a decrease in acquisition costs triggered by patent expiration, preceding NICE guidelines which themselves did not seem to affect prescription trends. Significant heterogeneity is observed in the prescription of the most cost-effective statin across GPs. A cost simulation shows that, between 2004 and 2018, the NHS could have saved £2.8bn (around 40% of the £6.3bn spent on statins during this time) if all GP practices had prescribed only the most cost-effective treatment. CONCLUSIONS There is potential for large savings for the NHS if new and, whenever possible, ongoing patients are promptly switched to the first medicine that becomes available as generic within a therapeutic class as long as it has similar efficacy to still-patented medicines.
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Affiliation(s)
- Matias Ortiz De Zarate
- Department of Economics, Faculty of Social Sciences, University of Southampton,Southampton SO17 1BJ, UK
| | - Emmanouil Mentzakis
- Department of Economics, Faculty of Social Sciences, University of Southampton,Southampton SO17 1BJ, UK
| | - Simon Ds Fraser
- School of Primary Care, Population Sciences and Medical Education, Faculty of Medicine, University of Southampton, Southampton General Hospital, Southampton SO16 6YD, UK
| | - Paul Roderick
- School of Primary Care, Population Sciences and Medical Education, Faculty of Medicine, University of Southampton, Southampton General Hospital, Southampton SO16 6YD, UK
| | - Paul Rutter
- School of Pharmacy and Biomedical Sciences, Faculty of Health and Science, 6697University of Portsmouth, Portsmouth PO1 2UP, UK
| | - Carmine Ornaghi
- Department of Economics, Faculty of Social Sciences, University of Southampton,Southampton SO17 1BJ, UK
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Bullock L, Bedson J, Chen Y, Chew-Graham CA, Campbell P. Comparative differences in musculoskeletal pain consultation and analgesic prescription for people with dementia: a UK-wide matched cohort study. Pain 2021; 162:2613-2620. [PMID: 33902094 DOI: 10.1097/j.pain.0000000000002257] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Accepted: 02/15/2021] [Indexed: 11/26/2022]
Abstract
ABSTRACT Painful musculoskeletal conditions are common in older adults; however, pain identification, assessment, and management are reported to be suboptimal for people with dementia. Adequate pain management is an integral aspect of care for people with dementia to prevent or delay negative outcomes, such as behavioural and psychological changes, emergency department attendance, and premature nursing home admission. This study aims to examine musculoskeletal consultations and analgesic prescriptions for people with dementia compared with those for people without dementia. A dementia cohort (n = 36,582) and matched cohort were identified in the Clinical Practice Research Datalink (a UK-wide primary care database). Period prevalence for musculoskeletal consultations and analgesic prescriptions was described, and logistic regression applied to estimate associations between dementia and musculoskeletal consultation or analgesic prescription from the time of dementia diagnosis to 5 years after diagnosis. People with dementia had a consistently (over time) lower prevalence and odds of musculoskeletal consultation and analgesic prescription compared with people without dementia. The evidence suggests that pain management may be suboptimal for people with dementia. These results highlight the need to increase awareness of pain and use better methods of pain assessment, evaluation of treatment response, and acceptable and effective management for people with dementia, in primary care.
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Affiliation(s)
- Laurna Bullock
- School of Medicine, Keele University, Staffordshire, United Kingdom
| | - John Bedson
- School of Medicine, Keele University, Staffordshire, United Kingdom
| | - Ying Chen
- School of Medicine, Keele University, Staffordshire, United Kingdom
- Department of Health and Environmental Sciences, Xi'an Jiaotong Liverpool University, Suzhou, China
| | - Carolyn A Chew-Graham
- School of Medicine, Keele University, Staffordshire, United Kingdom
- Midlands Partnership NHS Foundation Trust, St Georges' Hospital, Stafford, United Kingdom
| | - Paul Campbell
- School of Medicine, Keele University, Staffordshire, United Kingdom
- Midlands Partnership NHS Foundation Trust, St Georges' Hospital, Stafford, United Kingdom
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Yu D, Appleyard T, Cottrell E, Peat G. Co-prescription of gabapentinoids and opioids among adults with and without osteoarthritis in the United Kingdom between 1995 and 2017. Rheumatology (Oxford) 2020; 60:1942-1950. [DOI: 10.1093/rheumatology/keaa586] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Revised: 08/12/2020] [Indexed: 02/04/2023] Open
Abstract
Abstract
Objectives
To produce national and regional estimates and trends for gabapentinoid–opioid co-prescribing rates in patients with OA, both in absolute terms and relative to matched controls without OA.
Methods
Using the UK Clinical Practice Research Datalink database we first constructed age–sex–practice–date 1:1 matched cohorts of patients aged ≥40 years with and without a new diagnosis of OA between 1995–2017 and estimated the relative incidence of a first gabapentinoid prescription. Incident gabapentinoid users in both cohorts were followed to estimate and compare the event rate of gabapentinoid–opioid co-prescription (prescription from both classes within the same 28-day window).
Results
The incidence of first gabapentinoid prescription was 3-fold higher in patients with OA than in matched controls [n = 215 357; incidence rate ratio (IRR) 2.93; 95% CI: 2.87, 3.00]. Among incident gabapentinoid users with OA (n = 27 374, median follow-up 3.9 years) the event rate of gabapentinoid–opioid co-prescription was 4.03 (4.02–4.05) per person-year. The rate was higher in OA patients classed as long-term gabapentinoid users (6.24; 6.22–6.26). These rates were significantly higher than in incident gabapentinoid users without OA [adjusted-IRR: 1.29 (1.28–1.30)]. This elevated risk was observed across age, sex, geographic regions, and calendar years, when restricted to strong opioids and to long-term gabapentinoid users, and when co-prescription was defined as within 14 days and same-day prescribing.
Conclusions
Patients with OA not only have a higher risk of being prescribed a gabapentinoid but, once prescribed a gabapentinoid, are also at greater risk of opioid co-prescription. Strict restriction of gabapentinoid–opioid co-prescription, and improved access to, and uptake of, effective non-pharmacological and surgical alternatives for OA are required.
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Affiliation(s)
- Dahai Yu
- Primary Care Centre Versus Arthritis, School of Medicine, Community and Social Care, Keele University, Keele, UK
| | - Tom Appleyard
- Primary Care Centre Versus Arthritis, School of Medicine, Community and Social Care, Keele University, Keele, UK
| | - Elizabeth Cottrell
- Primary Care Centre Versus Arthritis, School of Medicine, Community and Social Care, Keele University, Keele, UK
| | - George Peat
- Primary Care Centre Versus Arthritis, School of Medicine, Community and Social Care, Keele University, Keele, UK
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Morales DR, Morant SV, MacDonald TM, Hallas J, Ernst MT, Pottegard A, Herings RMC, Smits E, Overbeek JA, Mackenzie IS, Doney ASF, Mitchell L, Bennie M, Robertson C, Wei L, Nicholson L, Morris C, Flynn RWV. Impact of EU regulatory label changes for diclofenac in people with cardiovascular disease in four countries: Interrupted time series regression analysis. Br J Clin Pharmacol 2020; 87:1129-1140. [PMID: 32668021 DOI: 10.1111/bcp.14478] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2020] [Revised: 06/29/2020] [Accepted: 07/05/2020] [Indexed: 12/17/2022] Open
Abstract
OBJECTIVE Due to cardiovascular safety concerns, the European Medicines Agency (EMA) recommended new contraindications and changes to product information for diclofenac across Europe in 2013. This study aims to measure their impact among targeted populations. METHOD Quarterly interrupted time series regression (ITS) analyses of diclofenac initiation among cohorts with contraindications (congestive cardiac failure [CHF], ischaemic heart disease [IHD], peripheral arterial disease [PAD], cerebrovascular disease [CVD]) and cautions (hypertension, hyperlipidaemia, diabetes) from Denmark, the Netherlands, England and Scotland. RESULTS The regulatory action was associated with significant immediate absolute reductions in diclofenac initiation in all countries for IHD (Denmark -0.08%, 95%CI -0.13, -0.03; England -0.09%, 95%CI -0.13 to -0.06%; the Netherlands -1.84%, 95%CI -2.51 to -1.17%; Scotland -0.34%, 95%CI -0.38 to -0.30%), PAD and hyperlipidaemia, the Netherlands, England and Scotland for hypertension and diabetes, and England and Scotland for CHF and CVD. Post-intervention there was a significant negative trend in diclofenac initiation in the Netherlands for IHD (-0.12%, 95%CI -0.19 to -0.04), PAD (-0.13%, 95%CI -0.22 to -0.05), hypertension, hyperlipidaemia and diabetes, and in Scotland for CHF (-0.01%, 95%CI -0.02 to -0.007%), IHD (-0.017, 95%CI -0.02, -0.01%), PAD and hypertension. In England, diclofenac initiation rates fell less steeply. In Denmark changes were more strongly associated with the earlier EMA 2012 regulatory action. CONCLUSION Although significant reductions in diclofenac initiation occurred, patients with contraindications continued to be prescribed diclofenac, the extent of which varied by country and target condition. Understanding reasons for such variation may help to guide the design or dissemination of future safety warnings.
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Affiliation(s)
| | | | | | | | | | | | - Ron M C Herings
- PHARMO Institute for Drug Outcomes Research, The Netherlands.,Department of Epidemiology and Data Science, Amsterdam UMC
| | - Elisabeth Smits
- PHARMO Institute for Drug Outcomes Research, The Netherlands
| | | | | | | | | | - Marion Bennie
- University of Strathclyde, UK.,NHS National Services, Scotland, UK
| | | | - Li Wei
- University College London, UK
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Curtis HJ, Walker AJ, MacKenna B, Croker R, Goldacre B. Prescription of suboptimal statin treatment regimens: a retrospective cohort study of trends and variation in English primary care. Br J Gen Pract 2020; 70:e525-e533. [PMID: 32601055 PMCID: PMC7357867 DOI: 10.3399/bjgp20x710873] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2019] [Accepted: 01/06/2020] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Since 2014 English national guidance recommends 'high-intensity' statins, reducing low-density lipoprotein (LDL) cholesterol by ≥40%. AIM To describe trends and variation in low-/medium-intensity statin prescribing and assess the feasibility of rapid prescribing behaviour change. DESIGN AND SETTING A retrospective cohort study using OpenPrescribing data from all 8142 standard NHS general practices in England from August 2010 to March 2019. METHOD Statins were categorised as high- or low-/medium-intensity using two different thresholds, and the proportion prescribed below these thresholds was calculated. The authors plotted trends and geographical variation, carried out mixed-effects logistic regression to identify practice characteristics associated with breaching of guidance, and used indicator saturation to identify sudden prescribing changes. RESULTS The proportion of statins prescribed below the recommended 40% LDL-lowering threshold has decreased gradually from 80% in 2011/2012 to 45% in 2019; the proportion below a pragmatic 37% threshold decreased from 30% to 18% in 2019. Guidance from 2014 had minimal impact on trends. Wide variation was found between practices (interdecile ranges 20% to 85% and 10% to 30% respectively in 2018). Regression identified no strong associations with breaching of guidance. Indicator saturation identified several practices exhibiting sudden changes towards greater guideline compliance. CONCLUSION Breaches of guidance on choice of statin remain common, with substantial variation between practices. Some have implemented rapid change, indicating the feasibility of rapid prescribing behaviour change. This article discusses the potential for a national strategic approach, using data and evidence to optimise care, including targeted education alongside audit and feedback to outliers through services such as OpenPrescribing.
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Affiliation(s)
- Helen J Curtis
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford
| | - Alex J Walker
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford
| | - Brian MacKenna
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford
| | - Richard Croker
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford
| | - Ben Goldacre
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford
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12
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Millar B, McWilliams DF, Abhishek A, Akin-Akinyosoye K, Auer DP, Chapman V, Doherty M, Ferguson E, Gladman JRF, Greenhaff P, Stocks J, Valdes AM, Walsh DA. Investigating musculoskeletal health and wellbeing; a cohort study protocol. BMC Musculoskelet Disord 2020; 21:182. [PMID: 32199451 PMCID: PMC7085148 DOI: 10.1186/s12891-020-03195-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Accepted: 03/09/2020] [Indexed: 12/17/2022] Open
Abstract
Background In an ageing population, pain, frailty and disability frequently coexist across a wide range of musculoskeletal diagnoses, but their associations remain incompletely understood. The Investigating Musculoskeletal Health and Wellbeing (IMH&W) study aims to measure and characterise the development and progression of pain, frailty and disability, and to identify discrete subgroups and their associations. The survey will form a longitudinal context for nested research, permitting targeted recruitment of participants for qualitative, observational and interventional studies; helping to understand recruitment bias in clinical studies; and providing a source cohort for cohort randomised controlled trials. Methods IMH&W will comprise a prospective cohort of 10,000 adults recruited through primary and secondary care, and through non-clinical settings. Data collection will be at baseline, and then through annual follow-ups for 4 years. Questionnaires will address demographic characteristics, pain severity (0–10 Numerical Rating Scale), pain distribution (reported on a body Manikin), pain quality (McGill Pain Questionnaire), central aspects of pain (CAP-Knee), frailty and disability (based on Fried criteria and the FRAIL questionnaire), and fracture risk. Baseline characteristics, progression and associations of frailty, pain and disability will be determined. Discrete subgroups and trajectories will be sought by latent class analysis. Recruitment bias will be explored by comparing participants in nested studies with the eligible IMH&W population. Discussion IMH&W will elucidate associations and progression of pain, frailty and disability. It will enable identification of people at risk of poor musculoskeletal health and wellbeing outcomes who might be suitable for specific interventions, and facilitate generalisation and comparison of research outcomes between target populations. The study will benefit from a large sample size and will recruit from diverse regions across the UK. Purposive recruitment will enrich the cohort with people with MSK problems with high representation of elderly and unwell people. Trial registration Clinicaltrials.gov NCT03696134. Date of Registration: 04 October 2018.
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Affiliation(s)
- Bonnie Millar
- NIHR Biomedical Research Centre, Academic Rheumatology, University of Nottingham Clinical Sciences Building, City Hospital, Nottingham, NG5 1PB, UK.,Division of ROD, School of Medicine, University of Nottingham, Nottingham, UK.,Pain Centre Versus Arthritis, University of Nottingham, Nottingham, UK
| | - Daniel F McWilliams
- NIHR Biomedical Research Centre, Academic Rheumatology, University of Nottingham Clinical Sciences Building, City Hospital, Nottingham, NG5 1PB, UK.,Division of ROD, School of Medicine, University of Nottingham, Nottingham, UK.,Pain Centre Versus Arthritis, University of Nottingham, Nottingham, UK
| | - Abhishek Abhishek
- NIHR Biomedical Research Centre, Academic Rheumatology, University of Nottingham Clinical Sciences Building, City Hospital, Nottingham, NG5 1PB, UK.,Division of ROD, School of Medicine, University of Nottingham, Nottingham, UK.,Pain Centre Versus Arthritis, University of Nottingham, Nottingham, UK
| | - Kehinde Akin-Akinyosoye
- NIHR Biomedical Research Centre, Academic Rheumatology, University of Nottingham Clinical Sciences Building, City Hospital, Nottingham, NG5 1PB, UK.,Division of ROD, School of Medicine, University of Nottingham, Nottingham, UK.,Pain Centre Versus Arthritis, University of Nottingham, Nottingham, UK
| | - Dorothee P Auer
- NIHR Biomedical Research Centre, Academic Rheumatology, University of Nottingham Clinical Sciences Building, City Hospital, Nottingham, NG5 1PB, UK.,Pain Centre Versus Arthritis, University of Nottingham, Nottingham, UK.,Division of Clinical Neuroscience, School of Medicine, University of Nottingham, Nottingham, UK
| | - Victoria Chapman
- NIHR Biomedical Research Centre, Academic Rheumatology, University of Nottingham Clinical Sciences Building, City Hospital, Nottingham, NG5 1PB, UK.,Pain Centre Versus Arthritis, University of Nottingham, Nottingham, UK.,School of Life Sciences, University of Nottingham, Nottingham, UK
| | - Michael Doherty
- NIHR Biomedical Research Centre, Academic Rheumatology, University of Nottingham Clinical Sciences Building, City Hospital, Nottingham, NG5 1PB, UK.,Division of ROD, School of Medicine, University of Nottingham, Nottingham, UK.,Pain Centre Versus Arthritis, University of Nottingham, Nottingham, UK
| | - Eamonn Ferguson
- NIHR Biomedical Research Centre, Academic Rheumatology, University of Nottingham Clinical Sciences Building, City Hospital, Nottingham, NG5 1PB, UK.,Pain Centre Versus Arthritis, University of Nottingham, Nottingham, UK.,School of Psychology, University of Nottingham, Nottingham, UK
| | - John R F Gladman
- NIHR Biomedical Research Centre, Academic Rheumatology, University of Nottingham Clinical Sciences Building, City Hospital, Nottingham, NG5 1PB, UK.,Rehabilitation, Ageing and Wellbeing, School of Medicine, University of Nottingham, Nottingham, UK
| | - Paul Greenhaff
- NIHR Biomedical Research Centre, Academic Rheumatology, University of Nottingham Clinical Sciences Building, City Hospital, Nottingham, NG5 1PB, UK.,Division of Physiology, Pharmacology and Neuroscience, University of Nottingham, Nottingham, UK
| | - Joanne Stocks
- NIHR Biomedical Research Centre, Academic Rheumatology, University of Nottingham Clinical Sciences Building, City Hospital, Nottingham, NG5 1PB, UK.,Division of ROD, School of Medicine, University of Nottingham, Nottingham, UK.,Pain Centre Versus Arthritis, University of Nottingham, Nottingham, UK
| | - Ana M Valdes
- NIHR Biomedical Research Centre, Academic Rheumatology, University of Nottingham Clinical Sciences Building, City Hospital, Nottingham, NG5 1PB, UK.,Division of ROD, School of Medicine, University of Nottingham, Nottingham, UK.,Pain Centre Versus Arthritis, University of Nottingham, Nottingham, UK
| | - David A Walsh
- NIHR Biomedical Research Centre, Academic Rheumatology, University of Nottingham Clinical Sciences Building, City Hospital, Nottingham, NG5 1PB, UK. .,Division of ROD, School of Medicine, University of Nottingham, Nottingham, UK. .,Pain Centre Versus Arthritis, University of Nottingham, Nottingham, UK. .,Sherwood Forest Hospitals NHS Foundation Trust, Sutton in Ashfield, Nottinghamshire, UK.
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13
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Weatherburn CJ, Guthrie B, Dreischulte T, Morales DR. Impact of medicines regulatory risk communications in the UK on prescribing and clinical outcomes: Systematic review, time series analysis and meta-analysis. Br J Clin Pharmacol 2019; 86:698-710. [PMID: 31465123 DOI: 10.1111/bcp.14104] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2019] [Revised: 08/13/2019] [Accepted: 08/20/2019] [Indexed: 12/18/2022] Open
Abstract
AIMS Regulatory risk communications are important to ensure medication safety, but their impact is poorly understood. The aim was to quantify the impact of UK risk communications on medication use and other outcomes. METHODS We conducted a systematic review of studies reporting prescribing/health outcome data relevant to UK regulatory risk communication. Data were reanalysed using interrupted time series regression 12 months after each regulatory intervention. Mean changes were pooled using random-effects generic inverse variance examining the following subgroups: drug withdrawals; restrictions/changes in indications; be aware messages without specific recommendations for action; communication via direct healthcare practitioner communications; communication via drug bulletins. RESULTS Of 11 466 articles screened, 40 studies examining 25 UK regulatory risk communications were included. Product withdrawals, restriction in indications and be aware communications were associated with relative mean changes of -78% (95% confidence interval [CI] -60 to -96%), -34% (95% confidence interval [CI] -12 to -55%) and -11% (95%CI -8 to -15%) in targeted drug prescribing respectively. Direct healthcare professional communications were associated with relative mean changes of -47% (95%CI -27 to -68%) compared to -13% (95%CI -6 to -20%) for drug bulletins. Of 7 studies examining unique health outcomes related to the safety concern, risk communications were associated with a mean -10% (95%CI -3 to -16%) decrease in intended and a 7% (95%CI 4 to 10%) increase in unintended health outcomes. DISCUSSION UK regulatory risk communications were associated with significant changes in targeted prescribing and potential changes in clinical outcomes. Further research is needed to systematically study the impact of regulatory interventions.
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Affiliation(s)
| | - Bruce Guthrie
- General Practice, Centre for Population Health Sciences, Usher Institute, University of Edinburgh, UK
| | - Tobias Dreischulte
- Clinical Health Services Research, Institute of General Practice and Family Medicine, University Hospital of Ludwig-Maximilians-University Munich, Germany
| | - Daniel R Morales
- Discovery Fellow and General Practitioner, Division of Population Health and Genomics, University of Dundee, UK
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14
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Welsh VK, Mallen CD, Ogollah R, Wilkie R, McBeth J. Investigating multisite pain as a predictor of self-reported falls and falls requiring health care use in an older population: A prospective cohort study. PLoS One 2019; 14:e0226268. [PMID: 31826023 PMCID: PMC6905547 DOI: 10.1371/journal.pone.0226268] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2019] [Accepted: 11/24/2019] [Indexed: 11/21/2022] Open
Abstract
Older people are continuing to fall despite fall prevention guidelines targeting known falls’ risk factors. Multisite pain is a potential novel falls’ risk factor requiring further exploration. This study hypothesises that: (1) an increasing number of pain sites and widespread pain predicts self-reported falls and falls recorded in primary and secondary healthcare records; (2) those relationships are independent of known falls’ risk factors and putative confounders. This prospective cohort study linked data from self-completed questionnaires, primary care electronic health records, secondary care admission statistics and national mortality data. Between 2002–2005, self-completion questionnaires were mailed to community-dwelling individuals aged 50 years and older registered with one of eight general practices in North Staffordshire, UK(n = 26,129) yielding 18,497 respondents. 11,375 respondents entered the study; 4386 completed six year follow-up. Self-reported falls were extracted from three and six year follow-up questionnaires. Falls requiring healthcare were extracted from routinely collected primary and secondary healthcare data. Increasing number of pain sites increased odds of future 3 year (odds ratio 1.12 (95% confidence interval: 1.01–1.24)) and 6 year self-reported fall (odds ratio 1.02 (1.00–1.03)) and increased hazard of future fall requiring primary healthcare (hazard ratio 1.01 (1.00–1.03)). The presence of widespread pain increased odds of future 3 year (odds ratio 1.27 (0.92–1.75)) and 6 year fall (odds ratio 1.43(1.06–1.95)) and increased hazard of future fall requiring primary healthcare (hazard ratio 1.27(0.98–1.65)). Multisite pain was not associated with future fall requiring secondary care admission. Multisite pain must be included as a falls’ risk factor in guidelines to ensure clinicians identify their older patients at risk of falls and employ timely implementation of current falls prevention strategies.
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Affiliation(s)
- Victoria K. Welsh
- Arthritis Research UK Primary Care Centre, Research Institute for Primary Care & Health Sciences, Keele University, Staffordshire, United Kingdom
- * E-mail:
| | - Christian D. Mallen
- Arthritis Research UK Primary Care Centre, Research Institute for Primary Care & Health Sciences, Keele University, Staffordshire, United Kingdom
| | - Reuben Ogollah
- Faculty of Medicine & Health Sciences, South Block, Queen’s Medical Centre, Nottingham, United Kingdom
| | - Ross Wilkie
- Arthritis Research UK Primary Care Centre, Research Institute for Primary Care & Health Sciences, Keele University, Staffordshire, United Kingdom
| | - John McBeth
- Arthritis Research UK Centre for Epidemiology, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, United Kingdom
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15
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Hedenmalm K, Blake K, Donegan K, Macia MA, Gil M, Williams J, Montero D, Candore G, Morales D, Kurz X, Arlett P. A European multicentre drug utilisation study of the impact of regulatory measures on prescribing of codeine for pain in children. Pharmacoepidemiol Drug Saf 2019; 28:1086-1096. [PMID: 31219227 PMCID: PMC6771637 DOI: 10.1002/pds.4836] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2018] [Revised: 03/01/2019] [Accepted: 04/23/2019] [Indexed: 12/19/2022]
Abstract
Purpose In June 2013, following recommendations from the World Health Organization (WHO) and Food and Drug Administration (FDA), the European Medicines Agency agreed updates to the codeine product information regarding use for pain in children younger than 12 years and children undergoing tonsillectomy or adenoidectomy (TA) for obstructive sleep apnoea. This study was conducted to (a) assess effectiveness of these measures on codeine prescribing in the “real‐world” setting and (b) test feasibility of a study using a common protocol by regulators with access to databases. Methods The study was performed using BIFAP (Spain), CPRD (UK), and IMS® Disease Analyzer (France and Germany) databases. Prescribers included general practitioners (GPs) (France and UK), GPs and paediatricians together (Spain), and GPs, paediatricians, and ear, nose, and throat (ENT) specialists separately (Germany). Between January 2010 and June 2015, prevalence of codeine prescribing was obtained every 6 months, and a time series analysis (joinpoint) was performed. Codeine prescribing within ±30 days of TA was also identified. Furthermore, doses, durations, and prior prescribing of other analgesics were investigated. Results Over the 5‐year period, codeine prescribing decreased in children younger than 12 years (by 84% in France and Spain, 44% in GP practices in Germany, and 33% in the United Kingdom). The temporal pattern was compatible with the regulatory intervention in France and the United Kingdom, whereas a decrease throughout the study period was seen in Germany and Spain. Decreased prescribing associated with TA was suggested in ENT practices in Germany. Conclusions Codeine prescribing for children decreased in line with introduced regulatory measures. Multidatabase studies assessing impact of measures by EU regulators are feasible.
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Affiliation(s)
- Karin Hedenmalm
- Business, Data and Analytics Department, European Medicines Agency, London, UK
| | - Kevin Blake
- Specialised Scientific Disciplines Department, European Medicines Agency, London, UK
| | - Katherine Donegan
- Vigilance and Risk Management of Medicines, Medicines and Healthcare Products Regulatory Agency, London, UK
| | - Miguel-Angel Macia
- Division of Pharmacoepidemiology and Pharmacovigilance, Spanish Agency for Medicines and Medical Devices, Madrid, Spain
| | - Miguel Gil
- Division of Pharmacoepidemiology and Pharmacovigilance, Spanish Agency for Medicines and Medical Devices, Madrid, Spain
| | - Julie Williams
- Pharmacovigilance and Risk Management Planning, Medicines and Healthcare Products Regulatory Agency, London, UK
| | - Dolores Montero
- Division of Pharmacoepidemiology and Pharmacovigilance, Spanish Agency for Medicines and Medical Devices, Madrid, Spain.,Spanish Medicines & Medical Devices Agency (Agencia Española de Medicamentos y Productos Sanitarios), Madrid, Spain
| | - Gianmario Candore
- Business, Data and Analytics Department, European Medicines Agency, London, UK
| | - Daniel Morales
- Pharmacovigilance and Epidemiology Department, European Medicines Agency, London, UK
| | - Xavier Kurz
- Pharmacovigilance and Epidemiology Department, European Medicines Agency, London, UK
| | - Peter Arlett
- Pharmacovigilance and Epidemiology Department, European Medicines Agency, London, UK
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16
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Bullock L, Bedson J, Jordan JL, Bartlam B, Chew-Graham CA, Campbell P. Pain assessment and pain treatment for community-dwelling people with dementia: A systematic review and narrative synthesis. Int J Geriatr Psychiatry 2019; 34:807-821. [PMID: 30724409 DOI: 10.1002/gps.5078] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2018] [Accepted: 01/26/2019] [Indexed: 01/01/2023]
Abstract
OBJECTIVES To describe the current literature on pain assessment and pain treatment for community-dwelling people with dementia. METHOD A comprehensive systematic search of the literature with narrative synthesis was conducted. Eight major bibliographic databases were searched in October 2018. Titles, abstracts, and full-text articles were sequentially screened. Standardised data extraction and quality appraisal exercises were conducted. RESULTS Thirty-two studies were included in the review, 11 reporting findings on pain assessment tools or methods and 27 reporting findings on treatments for pain. In regard to pain assessment, a large proportion of people with moderate to severe dementia were unable to complete a self-report pain instrument. Pain was more commonly reported by informal caregivers than the person with dementia themselves. Limited evidence was available for pain-focused behavioural observation assessment. In regard to pain treatment, paracetamol use was more common in community-dwelling people with dementia compared with people without dementia. However, non-steroidal anti-inflammatory drugs (NSAIDs) were used less. For stronger analgesics, community-dwelling people with dementia were more likely to receive strong opioids (eg, fentanyl) than people without dementia. CONCLUSION This review identifies a dearth of high-quality studies exploring pain assessment and/or treatment for community-dwelling people with dementia, not least into non-pharmacological interventions. The consequences of this lack of evidence, given the current and projected prevalence of the disease, are very serious and require urgent redress. In the meantime, clinicians should adopt a patient- and caregiver-centred, multi-dimensional, longitudinal approach to pain assessment and pain treatment for this population.
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Affiliation(s)
- Laurna Bullock
- Research Institute for Primary Care and Health Sciences, Keele University, Staffordshire, UK
| | - John Bedson
- Research Institute for Primary Care and Health Sciences, Keele University, Staffordshire, UK
| | - Joanne L Jordan
- Research Institute for Primary Care and Health Sciences, Keele University, Staffordshire, UK
| | - Bernadette Bartlam
- Research Institute for Primary Care and Health Sciences, Keele University, Staffordshire, UK
- Family Medicine and Primary Care, Lee Kong Chian School of Medicine, Nanyang Technical University, Singapore, Singapore
| | - Carolyn A Chew-Graham
- Research Institute for Primary Care and Health Sciences, Keele University, Staffordshire, UK
- Midlands Partnership NHS Foundation Trust, St George's Hospital, UK
| | - Paul Campbell
- Research Institute for Primary Care and Health Sciences, Keele University, Staffordshire, UK
- Midlands Partnership NHS Foundation Trust, St George's Hospital, UK
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17
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Curtis HJ, Dennis JM, Shields BM, Walker AJ, Bacon S, Hattersley AT, Jones AG, Goldacre B. Time trends and geographical variation in prescribing of drugs for diabetes in England from 1998 to 2017. Diabetes Obes Metab 2018; 20:2159-2168. [PMID: 29732725 PMCID: PMC6099452 DOI: 10.1111/dom.13346] [Citation(s) in RCA: 53] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2018] [Revised: 04/20/2018] [Accepted: 05/01/2018] [Indexed: 12/21/2022]
Abstract
AIMS To measure the variation in prescribing of second-line non-insulin diabetes drugs. MATERIALS AND METHODS We evaluated time trends for the period 1998 to 2016, using England's publicly available prescribing datasets, and stratified these by the order in which they were prescribed to patients using the Clinical Practice Research Datalink. We calculated the proportion of each class of diabetes drug as a percentage of the total per year. We evaluated geographical variation in prescribing using general practice-level data for the latest 12 months (to August 2017), with aggregation to Clinical Commissioning Groups. We calculated percentiles and ranges, and plotted maps. RESULTS Prescribing of therapy after metformin is changing rapidly. Dipeptidyl peptidase-4 (DPP-4) inhibitor use has increased markedly, with DPP-4 inhibitors now the most common second-line drug (43% prescriptions in 2016). The use of sodium-glucose co-transporter-2 (SGLT-2) inhibitors also increased rapidly (14% new second-line, 27% new third-line prescriptions in 2016). There was wide geographical variation in choice of therapies and average spend per patient. In contrast, metformin was consistently used as a first-line treatment in accordance with guidelines. CONCLUSIONS In England there is extensive geographical variation in the prescribing of diabetes drugs after metformin, and increasing use of higher-cost DPP-4 inhibitors and SGLT-2 inhibitors compared with low-cost sulphonylureas. Our findings strongly support the case for comparative effectiveness trials of current diabetes drugs.
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Affiliation(s)
- Helen J. Curtis
- Evidence‐Based Medicine DataLab, Nuffield Department of Primary Care Health SciencesUniversity of OxfordOxfordUK
| | - John M. Dennis
- Health Statistics Group, Institute of Health Research, University of Exeter Medical SchoolExeterUK
| | - Beverley M. Shields
- Royal Devon and Exeter Hospital, Institute of Biomedical and Clinical Science, University of Exeter Medical SchoolExeterUK
| | - Alex J. Walker
- Evidence‐Based Medicine DataLab, Nuffield Department of Primary Care Health SciencesUniversity of OxfordOxfordUK
| | - Seb Bacon
- Evidence‐Based Medicine DataLab, Nuffield Department of Primary Care Health SciencesUniversity of OxfordOxfordUK
| | - Andrew T. Hattersley
- Royal Devon and Exeter Hospital, Institute of Biomedical and Clinical Science, University of Exeter Medical SchoolExeterUK
| | - Angus G. Jones
- Royal Devon and Exeter Hospital, Institute of Biomedical and Clinical Science, University of Exeter Medical SchoolExeterUK
| | - Ben Goldacre
- Evidence‐Based Medicine DataLab, Nuffield Department of Primary Care Health SciencesUniversity of OxfordOxfordUK
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18
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Chen Y, Bedson J, Hayward RA, Jordan KP. Trends in prescribing of non-steroidal anti-inflammatory drugs in patients with cardiovascular disease: influence of national guidelines in UK primary care. Fam Pract 2018; 35:426-432. [PMID: 29365071 DOI: 10.1093/fampra/cmx142] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Non-steroidal anti-inflammatory drugs (NSAIDs) are commonly used to treat pain, but have potential side effects in patients with cardiovascular disease (CVD). OBJECTIVES To determine trends in NSAIDs prescribing between 2002 and 2010 in patients with CVD, and ascertain whether prescribing patterns changed following publication of major national (the Medicines and Healthcare products Regulatory Agency (MHRA) and the National Institute for Health and Clinical Excellence (NICE)) guidance to GPs. METHODS This was an observational database study of adult patients in 11 practices (Staffordshire, England). NSAIDs were categorised into basic, COX-2 and topical. Study duration was divided on a quarterly basis from 2002-quarter-1 to 2010q4. CVD patients were identified using pre-defined Read Codes recorded in the two years prior to each quarter. Quarterly prevalence was determined. Times of significant changes in prescribing trends were determined using Joinpoint Regression, and compared to dates of the five major guidelines (in 2004q4, 2005q1, 2005q3, 2006q4, 2008q1). RESULTS In CVD patients, the prescription of basic NSAIDs showed a decreasing trend throughout the study period, from 774 (95% CI, 691-863) per 10000 patients in 2002q1 to 245 (204-291) in 2010q4. COX-2 prescribing increased from 232/10000 (187-286) in 2002q1 to 403/10000 (348-464) in 2004q3. Prescribing then fell sharply to 102/10000 (76-134) in 2005q2 before stabilising around 55/10000. Topical NSAIDs prescribing showed a steady increase, starting at 115/10000 (108-123) in 2002q1 and ending at 270/10000 (258-281) in 2010q4. Similar trends were observed in patients without CVD, particularly a sharp drop in COX-2 prescribing also occurred from 2004q4 when initial MHRA guidance was issued. CONCLUSION Despite guidelines and a trend toward decreased prescribing, the use of potentially harmful NSAIDs continued in CVD patients. The MHRA directives potentially might have affected patients without CVD who may have inappropriately restricted their use of COX-2.
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Affiliation(s)
- Ying Chen
- Arthritis Research UK Primary Care Centre, Research Institute for Primary Care and Health Sciences, Keele University, Keele, Staffordshire, UK
| | - John Bedson
- Arthritis Research UK Primary Care Centre, Research Institute for Primary Care and Health Sciences, Keele University, Keele, Staffordshire, UK
| | - Richard A Hayward
- Arthritis Research UK Primary Care Centre, Research Institute for Primary Care and Health Sciences, Keele University, Keele, Staffordshire, UK
| | - Kelvin P Jordan
- Arthritis Research UK Primary Care Centre, Research Institute for Primary Care and Health Sciences, Keele University, Keele, Staffordshire, UK
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19
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Gilardi F, Augsburger M, Thomas A. Will Widespread Synthetic Opioid Consumption Induce Epigenetic Consequences in Future Generations? Front Pharmacol 2018; 9:702. [PMID: 30018553 PMCID: PMC6037745 DOI: 10.3389/fphar.2018.00702] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2018] [Accepted: 06/11/2018] [Indexed: 11/13/2022] Open
Abstract
A growing number of evidence demonstrates that ancestral exposure to xenobiotics (pollutants, drugs of abuse, etc.) can perturb the physiology and behavior of descendants. Both maternal and paternal transmission of phenotype across generations has been proved, demonstrating that parental drug history may have significant implications for subsequent generations. In the last years, the burden of novel synthetic opioid (NSO) consumption, due to increased medical prescription of pain medications and to easier accessibility of these substances on illegal market, is raising new questions first in term of public health, but also about the consequences of the parental use of these drugs on future generations. Besides being associated to the neonatal abstinence syndrome, in utero exposure to opioids has an impact on neuronal development with long-term repercussions that are potentially transmitted to subsequent generations. In addition, recent reports suggest that opioid use even before conception influences the reactivity to opioids of the progeny and the following generations, likely through epigenetic mechanisms. This review describes the current knowledge about the transgenerational effects of opioid consumption. We summarize the preclinical and clinical findings showing the implications for the subsequent generations of parental exposure to opioids earlier in life. Limitations of the existing data on NSOs and new perspectives of the research are also discussed, as well as clinical and forensic consequences.
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Affiliation(s)
- Federica Gilardi
- Forensic Toxicology and Chemistry Unit, University Center of Legal Medicine, Lausanne University Hospital - Geneva University Hospitals, Geneva, Switzerland.,Faculty of Biology and Medicine, University of Lausanne, Lausanne, Switzerland
| | - Marc Augsburger
- Forensic Toxicology and Chemistry Unit, University Center of Legal Medicine, Lausanne University Hospital - Geneva University Hospitals, Geneva, Switzerland
| | - Aurelien Thomas
- Forensic Toxicology and Chemistry Unit, University Center of Legal Medicine, Lausanne University Hospital - Geneva University Hospitals, Geneva, Switzerland.,Faculty of Biology and Medicine, University of Lausanne, Lausanne, Switzerland
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20
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Goedecke T, Morales DR, Pacurariu A, Kurz X. Measuring the impact of medicines regulatory interventions - Systematic review and methodological considerations. Br J Clin Pharmacol 2018; 84:419-433. [PMID: 29105853 PMCID: PMC5809349 DOI: 10.1111/bcp.13469] [Citation(s) in RCA: 54] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2017] [Revised: 10/24/2017] [Accepted: 10/31/2017] [Indexed: 12/20/2022] Open
Abstract
AIMS Evaluating the public health impact of regulatory interventions is important but there is currently no common methodological approach to guide this evaluation. This systematic review provides a descriptive overview of the analytical methods for impact research. METHODS We searched MEDLINE and EMBASE for articles with an empirical analysis evaluating the impact of European Union or non-European Union regulatory actions to safeguard public health published until March 2017. References from systematic reviews and articles from other known sources were added. Regulatory interventions, data sources, outcomes of interest, methodology and key findings were extracted. RESULTS From 1246 screened articles, 229 were eligible for full-text review and 153 articles in English language were included in the descriptive analysis. Over a third of articles studied analgesics and antidepressants. Interventions most frequently evaluated are regulatory safety communications (28.8%), black box warnings (23.5%) and direct healthcare professional communications (10.5%); 55% of studies measured changes in drug utilization patterns, 27% evaluated health outcomes, and 18% targeted knowledge, behaviour or changes in clinical practice. Unintended consequences like switching therapies or spill-over effects were rarely evaluated. Two-thirds used before-after time series and 15.7% before-after cross-sectional study designs. Various analytical approaches were applied including interrupted time series regression (31.4%), simple descriptive analysis (28.8%) and descriptive analysis with significance tests (23.5%). CONCLUSION Whilst impact evaluation of pharmacovigilance and product-specific regulatory interventions is increasing, the marked heterogeneity in study conduct and reporting highlights the need for scientific guidance to ensure robust methodologies are applied and systematic dissemination of results occurs.
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Affiliation(s)
- Thomas Goedecke
- Pharmacovigilance and Epidemiology Department, Inspections Human Medicines Pharmacovigilance and Committees DivisionEuropean Medicines Agency (EMA)LondonE14 5EUUK
| | - Daniel R. Morales
- Pharmacovigilance and Epidemiology Department, Inspections Human Medicines Pharmacovigilance and Committees DivisionEuropean Medicines Agency (EMA)LondonE14 5EUUK
- Division of Population Health SciencesUniversity of DundeeDundeeDD2 4BFUK
| | - Alexandra Pacurariu
- Pharmacovigilance and Epidemiology Department, Inspections Human Medicines Pharmacovigilance and Committees DivisionEuropean Medicines Agency (EMA)LondonE14 5EUUK
- Dutch Medicines Evaluation Board3531AHUtrechtThe Netherlands
| | - Xavier Kurz
- Pharmacovigilance and Epidemiology Department, Inspections Human Medicines Pharmacovigilance and Committees DivisionEuropean Medicines Agency (EMA)LondonE14 5EUUK
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Witkiewitz K, Vowles KE. Alcohol and Opioid Use, Co-Use, and Chronic Pain in the Context of the Opioid Epidemic: A Critical Review. Alcohol Clin Exp Res 2018; 42:478-488. [PMID: 29314075 PMCID: PMC5832605 DOI: 10.1111/acer.13594] [Citation(s) in RCA: 130] [Impact Index Per Article: 21.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2017] [Accepted: 12/29/2017] [Indexed: 12/20/2022]
Abstract
The dramatic increase in opioid misuse, opioid use disorder (OUD), and opioid-related overdose deaths in the United States has led to public outcry, policy statements, and funding initiatives. Meanwhile, alcohol misuse and alcohol use disorder (AUD) are a highly prevalent public health problem associated with considerable individual and societal costs. This study provides a critical review of alcohol and opioid misuse, including issues of prevalence, morbidity, and societal costs. We also review research on interactions between alcohol and opioid use, the influence of opioids and alcohol on AUD and OUD treatment outcomes, respectively, the role of pain in the co-use of alcohol and opioids, and treatment of comorbid OUD and AUD. Heavy drinking, opioid misuse, and chronic pain individually represent significant public health problems. Few studies have examined co-use of alcohol and opioids, but available data suggest that co-use is common and likely contributes to opioid overdose-related morbidity and mortality. Co-use of opioids and alcohol is related to worse outcomes in treatment for either substance. Finally, chronic pain frequently co-occurs with use (and co-use) of alcohol and opioids. Opioid use and alcohol use are also likely to complicate the treatment of chronic pain. Research on the interactions between alcohol and opioids, as well as treatment of the comorbid disorders is lacking. Currently, most alcohol research excludes patients with OUD and there is lack of measurement in both AUD and OUD research in relation to pain-related functioning. Research in those with chronic pain often assesses opioid use, but rarely assesses alcohol use or AUD. New research to examine the nexus of alcohol, opioids, and pain, as well as their treatment, is critically needed.
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Affiliation(s)
- Katie Witkiewitz
- Department of Psychology, University of New Mexico, Albuquerque, NM
| | - Kevin E Vowles
- Department of Psychology, University of New Mexico, Albuquerque, NM
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Buttorff C, Trujillo AJ, Castillo R, Vecino-Ortiz AI, Anderson GF. The impact of practice guidelines on opioid utilization for injured workers. Am J Ind Med 2017; 60:1023-1030. [PMID: 28990210 DOI: 10.1002/ajim.22779] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/30/2017] [Indexed: 12/20/2022]
Abstract
BACKGROUND Opioid use is rising in the US and may cause special problems in workers compensation cases, including addiction and preventing a return to work after an injury. OBJECTIVE This study evaluates a physician-level intervention to curb opioid usage. An insurer identified patients with out-of-guideline opioid utilization and called the prescribing physician to discuss the patient's treatment protocol. RESEARCH DESIGN This study uses a differences-in-differences study design with a propensity-score-matched control group. Medical and pharmaceutical claims data from 2005 to 2011 were used for analyses. RESULTS Following the intervention, the use of opioids increased for the intervention group and there is little impact on medical spending. CONCLUSIONS Counseling physicians about patients with high opioid utilization may focus more attention on their care, but did not impact short-term outcomes. More robust interventions may be needed to manage opioid use. PERSPECTIVE While the increasing use of opioids is of growing concern around the world, curbing the utilization of these powerfully addictive narcotics has proved elusive. This study examines a prescribing guidelines intervention designed to reduce the prescription of opioids following an injury. The study finds that there was little change in the opioid utilization after the intervention, suggesting interventions along other parts of the prescribing pathway may be needed.
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Affiliation(s)
| | - Antonio J. Trujillo
- Department of International Health; Johns Hopkins Bloomberg School of Public Health; Baltimore Maryland
| | - Renan Castillo
- Department of Health Policy and Management; Johns Hopkins Bloomberg School of Public Health; Baltimore Maryland
| | - Andres I. Vecino-Ortiz
- Department of International Health; Johns Hopkins Bloomberg School of Public Health; Baltimore Maryland
- Institute of Public Health; Universidad Javeriana; Bogota Colombia
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23
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Yu D, Jordan KP, Bedson J, Englund M, Blyth F, Turkiewicz A, Prieto-Alhambra D, Peat G. Population trends in the incidence and initial management of osteoarthritis: age-period-cohort analysis of the Clinical Practice Research Datalink, 1992-2013. Rheumatology (Oxford) 2017; 56:1902-1917. [PMID: 28977564 PMCID: PMC5850125 DOI: 10.1093/rheumatology/kex270] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2017] [Indexed: 12/31/2022] Open
Abstract
Objective To determine recent trends in the rate and management of new cases of OA presenting to primary healthcare using UK nationally representative data. Methods Using the Clinical Practice Research Datalink we identified new cases of diagnosed OA and clinical OA (including OA-relevant peripheral joint pain in those aged over 45 years) using established code lists. For both definitions we estimated annual incidence density using exact person-time, and undertook descriptive analysis and age-period-cohort modelling. Demographic characteristics and management were described for incident cases in each calendar year. Sensitivity analyses explored the robustness of the findings to key assumptions. Results Between 1992 and 2013 the annual age-sex standardized incidence rate for clinical OA increased from 29.2 to 40.5/1000 person-years. After controlling for period effects, the consultation incidence of clinical OA was higher for successive cohorts born after the mid-1950s, particularly women. In contrast, with the exception of hand OA, we observed no increase in the incidence of diagnosed OA: 8.6/1000 person-years in 2004 down to 6.3 in 2013. In 2013, 16.4% of clinical OA cases had an X-ray referral. While NSAID prescriptions fell from 2004, the proportion prescribed opioid analgesia rose markedly (0.1% of diagnosed OA in 1992 to 1.9% in 2013). Conclusion Rising rates of clinical OA, continued use of plain radiography and a shift towards opioid analgesic prescription are concerning. Our findings support the search for policies to tackle this common problem that promote joint pain prevention while avoiding excessive and inappropriate health care.
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Affiliation(s)
- Dahai Yu
- Research Institute for Primary Care & Health Sciences, Keele University, Keele, UK
| | - Kelvin P Jordan
- Research Institute for Primary Care & Health Sciences, Keele University, Keele, UK
| | - John Bedson
- Research Institute for Primary Care & Health Sciences, Keele University, Keele, UK
| | - Martin Englund
- Clinical Epidemiology Unit, Orthopaedics, Department of Clinical Sciences Lund, Lund University, Lund, Sweden
- Clinical Epidemiology Research & Training Unit, Boston University School of Medicine, Boston, MA, USA
| | - Fiona Blyth
- Concord Clinical School, Faculty of Medicine, University of Sydney, Sydney, New South Wales, Australia
| | - Aleksandra Turkiewicz
- Clinical Epidemiology Unit, Orthopaedics, Department of Clinical Sciences Lund, Lund University, Lund, Sweden
| | - Daniel Prieto-Alhambra
- GREMPAL (Grup de Recerca en Epidemiologia de les Malalties Prevalents de l’Aparell Locomotor), Idiap Jordi Gol Primary Care Research Institute, Universitat Autònoma de Barcelona, Barcelona, Spain
- Musculoskeletal Pharmaco- and Device Epidemiology, Nuffield Department of Orthopaedics, Rheumatology, and Musculoskeletal Sciences, University of Oxford, UK
| | - George Peat
- Research Institute for Primary Care & Health Sciences, Keele University, Keele, UK
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Guildford BJ, Daly-Eichenhardt A, Hill B, Sanderson K, McCracken LM. Analgesic reduction during an interdisciplinary pain management programme: treatment effects and processes of change. Br J Pain 2017; 12:72-86. [PMID: 29796259 DOI: 10.1177/2049463717734016] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Long-term use of opioid medication is associated with a host of negative effects on health and quality of life. Guidelines state that people with chronic pain taking high doses of opioids without benefit should be supported to discontinue them. Little research has investigated psychological processes associated with analgesic use and tapering. This study investigated (1) analgesic use pre- and post-participation in an interdisciplinary pain management programme and its relationship to functioning and (2) psychological processes associated with analgesic use. Opioid use was associated with poorer functioning at baseline. Participating in an interdisciplinary pain management programme was associated with reductions in opioid dose and number of classes of analgesics used. Reductions in analgesic use were associated with improvements in functioning. Psychological inflexibility was associated with using higher doses of opioid medication and with using a greater number of classes of analgesics. Psychological flexibility appears relevant in explaining analgesic use. Future research could focus on targeting this process to improve tapering outcomes.
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Affiliation(s)
- Beth J Guildford
- INPUT Pain Management Unit, St Thomas' Hospital, Guy's and St Thomas' NHS Foundation Trust, London, UK.,NIHR Maudsley Biomedical Research Centre, King's Health Partners, London, UK
| | - Aisling Daly-Eichenhardt
- INPUT Pain Management Unit, St Thomas' Hospital, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Bethany Hill
- INPUT Pain Management Unit, St Thomas' Hospital, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Karen Sanderson
- INPUT Pain Management Unit, St Thomas' Hospital, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Lance M McCracken
- INPUT Pain Management Unit, St Thomas' Hospital, Guy's and St Thomas' NHS Foundation Trust, London, UK.,Health Psychology Section, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
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Trends in long-term opioid prescribing in primary care patients with musculoskeletal conditions: an observational database study. Pain 2017; 157:1525-1531. [PMID: 27003191 PMCID: PMC4912234 DOI: 10.1097/j.pain.0000000000000557] [Citation(s) in RCA: 51] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Supplemental Digital Content is Available in the Text. Long-term opioid use decreased from 2011, but the proportion of more potent opioids prescribed increased. Ongoing review of effectiveness and need for discontinuation is important. Long-term opioids may benefit patients with chronic pain but have also been linked to harmful outcomes. In the United Kingdom, the predominant source of opioids is primary care prescription. The objective was to examine changes in the incidence, length, and opioid potency of long-term prescribing episodes for musculoskeletal conditions in UK primary care (2002-2013). This was an observational database study (Clinical Practice Research Datalink, 190 practices). Participants (≥18 years) were prescribed an opioid for a musculoskeletal condition (no opioid prescribed in previous 6 months), and issued ≥2 opioid prescriptions within 90 days (long-term episode). Opioids were divided into short- and long-acting noncontrolled and controlled drugs. Annual incidence of long-term opioid episodes was determined, and for those still in a long-term episode, the percentage of patients prescribed each type 1 to 2 years, and >2 years after initiation. Annual denominator population varied from 1.25 to 1.38 m. A total of 76,416 patients started 1 long-term episode. Annual long-term episode incidence increased (2002-2009) by 38% (42.4-58.3 per 10,000 person-years), remaining stable to 2011, then decreasing slightly to 55.8/10,000 (2013). Patients prescribed long-acting controlled opioids within the first 90 days of long-term use increased from 2002 to 2013 (2.3%-9.9%). In those still in a long-term opioid episode (>2 years), long-acting controlled opioid prescribing increased from 3.5% to 22.6%. This study has uniquely shown an increase in prescribing long-term opioids to 2009, gradually decreasing from 2011 in the United Kingdom. The trend was towards increased prescribing of controlled long-acting opioids and earlier use. Further research into the risks and benefits of opioids is required.
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26
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Mallen C, Hay E. Managing back pain and osteoarthritis without paracetamol: Physical treatments are the way forward. Br J Sports Med 2016; 50:1286-1287. [PMID: 27694103 DOI: 10.1136/bjsports-2015-h1352rep] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Affiliation(s)
- Christian Mallen
- Arthritis Research UK Primary Care Centre, Research Institute for Primary Care and Health Sciences, Keele University, Keele ST5 5BG, UK
| | - Elaine Hay
- Arthritis Research UK Primary Care Centre, Research Institute for Primary Care and Health Sciences, Keele University, Keele ST5 5BG, UK
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Foy R, Leaman B, McCrorie C, Petty D, House A, Bennett M, Carder P, Faulkner S, Glidewell L, West R. Prescribed opioids in primary care: cross-sectional and longitudinal analyses of influence of patient and practice characteristics. BMJ Open 2016; 6:e010276. [PMID: 27178970 PMCID: PMC4874107 DOI: 10.1136/bmjopen-2015-010276] [Citation(s) in RCA: 70] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES To examine trends in opioid prescribing in primary care, identify patient and general practice characteristics associated with long-term and stronger opioid prescribing, and identify associations with changes in opioid prescribing. DESIGN Trend, cross-sectional and longitudinal analyses of routinely recorded patient data. SETTING 111 primary care practices in Leeds and Bradford, UK. PARTICIPANTS We observed 471 828 patient-years in which all patients represented had at least 1 opioid prescription between April 2005 and March 2012. A cross-sectional analysis included 99 847 patients prescribed opioids between April 2011 and March 2012. A longitudinal analysis included 49 065 patient-years between April 2008 and March 2012. We excluded patients with cancer or treated for substance misuse. MAIN OUTCOME MEASURES Long-term opioid prescribing (4 or more prescriptions within 12 months), stronger opioid prescribing and stepping up to or down from stronger opioids. RESULTS Opioid prescribing in the adult population almost doubled for weaker opioids over 2005-2012 and rose over sixfold for stronger opioids. There was marked variation among general practices in the odds of patients stepping up to stronger opioids compared with those not stepping up (range 0.31-3.36), unexplained by practice-level variables. Stepping up to stronger opioids was most strongly associated with being underweight (adjusted OR 3.26, 1.49 to 7.17), increasing polypharmacy (4.15, 3.26 to 5.29 for 10 or more repeat prescriptions), increasing numbers of primary care appointments (3.04, 2.48 to 3.73 for over 12 appointments in the year) and referrals to specialist pain services (5.17, 4.37 to 6.12). Compared with women under 50 years, men under 50 were less likely to step down once prescribed stronger opioids (0.53, 0.37 to 0.75). CONCLUSIONS While clinicians should be alert to patients at risk of escalated opioid prescribing, much prescribing variation may be attributable to clinical behaviour. Effective strategies targeting clinicians and patients are needed to curb rising prescribing, especially of stronger opioids.
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Affiliation(s)
- Robbie Foy
- Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Ben Leaman
- Calderdale Metropolitan Borough Council, Halifax, UK
| | - Carolyn McCrorie
- Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Duncan Petty
- Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Allan House
- Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Michael Bennett
- Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Paul Carder
- Yorkshire & Humber Commissioning Support Unit, Bradford, UK
| | | | - Liz Glidewell
- Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Robert West
- Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
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28
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Jordan KP, Tan V, Edwards JJ, Chen Y, Englund M, Hubertsson J, Jöud A, Porcheret M, Turkiewicz A, Peat G. Influences on the decision to use an osteoarthritis diagnosis in primary care: a cohort study with linked survey and electronic health record data. Osteoarthritis Cartilage 2016; 24:786-93. [PMID: 26746149 PMCID: PMC4850243 DOI: 10.1016/j.joca.2015.12.015] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2015] [Revised: 11/04/2015] [Accepted: 12/16/2015] [Indexed: 02/02/2023]
Abstract
OBJECTIVE Clinicians may record patients presenting with osteoarthritis (OA) symptoms with joint pain rather than an OA diagnosis. This may have implications for OA research studies and patient care. The objective was to assess whether older adults recorded with joint pain are similar to those with a recorded OA diagnosis. METHOD A study of adults aged ≥50 years in eight United Kingdom general practices, with electronic health records linked to survey data. Patients with a recorded regional OA diagnosis were compared to those with a recorded joint pain symptom on socio-demographics, risk factors, body region, pain severity, prescribed analgesia, and potential differential diagnoses. A sub-group was compared on radiographic knee OA. RESULTS Thirteen thousand eight hundred and thirty-one survey responders consented to record review. One thousand four hundred and twenty-seven (10%) received an OA (n = 616) or joint pain (n = 811) code with wide practice variation. Receiving an OA diagnosis was associated with age (75+ compared to 50-64 OR 3.25; 95% Credible intervals (CrI) 2.36, 4.53), obesity (1.72; 1.22, 2.33), and pain interference (1.45; 1.09, 1.92). Analgesia management was similar. Radiographic OA was common in both groups. A quarter of those with a joint pain record received an OA diagnosis in the following 6 years. CONCLUSION Recording OA diagnoses are less common than recording a joint pain symptom and associated with risk factors and severity. OA studies in primary care need to consider joint pain symptoms to understand the burden and quality of care across the spectrum of OA. Patients recorded with joint pain may represent early cases of OA with need for early intervention.
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Affiliation(s)
- K P Jordan
- Research Institute for Primary Care and Health Sciences, Keele University, Keele, UK.
| | - V Tan
- Research Institute for Primary Care and Health Sciences, Keele University, Keele, UK.
| | - J J Edwards
- Research Institute for Primary Care and Health Sciences, Keele University, Keele, UK.
| | - Y Chen
- Research Institute for Primary Care and Health Sciences, Keele University, Keele, UK.
| | - M Englund
- Clinical Epidemiology Unit, Orthopaedics, Department of Clinical Sciences Lund, Lund University, Lund, Sweden; Clinical Epidemiology Research & Training Unit, Boston University School of Medicine, Boston, MA, USA.
| | - J Hubertsson
- Clinical Epidemiology Unit, Orthopaedics, Department of Clinical Sciences Lund, Lund University, Lund, Sweden.
| | - A Jöud
- Department of Laboratory Medicine, Division of Occupational and Environmental Medicine, Lund University, Lund, Sweden.
| | - M Porcheret
- Research Institute for Primary Care and Health Sciences, Keele University, Keele, UK.
| | - A Turkiewicz
- Clinical Epidemiology Unit, Orthopaedics, Department of Clinical Sciences Lund, Lund University, Lund, Sweden.
| | - G Peat
- Research Institute for Primary Care and Health Sciences, Keele University, Keele, UK.
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Lee SS, Choi Y, Pransky GS. Extent and Impact of Opioid Prescribing for Acute Occupational Low Back Pain in the Emergency Department. J Emerg Med 2016; 50:376-84.e1-2. [DOI: 10.1016/j.jemermed.2015.10.015] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2015] [Revised: 10/09/2015] [Accepted: 10/17/2015] [Indexed: 11/28/2022]
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Guthrie B, Yu N, Murphy D, Donnan PT, Dreischulte T. Measuring prevalence, reliability and variation in high-risk prescribing in general practice using multilevel modelling of observational data in a population database. HEALTH SERVICES AND DELIVERY RESEARCH 2015. [DOI: 10.3310/hsdr03420] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BackgroundHigh-risk primary care prescribing is common and is known to vary considerably between practices, but the extent to which high-risk prescribing varies among individual general practitioners (GPs) is not known.ObjectivesTo create prescribing safety indicators usable in existing electronic clinical data and to examine (1) variation in high-risk prescribing between patients, GPs and practices including reliability of measurement and (2) changes over time in high-risk prescribing prevalence and variation between practices.DesignDescriptive analysis and multilevel logistic regression modelling of routine data.SettingUK general practice using routine electronic medical record data.Participants(1) For analysis of variation and reliability, 398 GPs and 26,539 patients in 38 Scottish practices. (2) For analysis of change in high-risk prescribing, ≈ 300,000 patients particularly vulnerable to adverse drug effects registered with 190 Scottish practices.Main outcome measuresFor the analysis of variation between practices and between GPs, five indicators of high-risk non-steroidal anti-inflammatory drug (NSAID) prescribing. For the analysis of change in high-risk prescribing, 19 previously validated indicators.ResultsMeasurement of high-risk prescribing at GP level was feasible only for newly initiated drugs and for drugs similar to NSAIDs which are usually initiated by GPs. There was moderate variation between practices in total high-risk NSAID prescribing [intraclass correlation coefficient (ICC) 0.034], but this indicator was highly reliable (> 0.8 for all practices) at distinguishing between practices because of the large number of patients being measured. There was moderate variation in initiation of high-risk NSAID prescribing between practices (ICC 0.055) and larger variation between GPs (ICC 0.166), but measurement did not reliably distinguish between practices and had reliability > 0.7 for only half of the GPs in the study. Between quarter (Q)2 2004 and Q1 2009, the percentage of patients exposed to high-risk prescribing measured by 17 indicators that could be examined over the whole period fell from 8.5% to 5.2%, which was largely driven by reductions in high-risk NSAID and antiplatelet use. Variation between practices increased for five indicators and decreased for five, with no relationship between change in the rate of high-risk prescribing and change in variation between practices.ConclusionsHigh-risk prescribing is common and varies moderately between practices. High-risk prescribing at GP level cannot be easily measured routinely because of the difficulties in accurately identifying which GP actually prescribed the drug and because drug initiation is often a shared responsibility with specialists. For NSAID initiation, there was approximately three times greater variation between GPs than between practices. Most GPs with above average high-risk prescribing worked in practices which were not themselves above average. The observed reductions in high-risk prescribing between 2004 and 2009 were largely driven by falls in NSAID and antiplatelet prescribing, and there was no relationship between change in rate and change in variation between practices. These results are consistent with improvement interventions in all practices being more appropriate than interventions targeted on practices or GPs with higher than average high-risk prescribing. There is a need for research to understand why high-risk prescribing varies and to design and evaluate interventions to reduce it.FundingFunding for this study was provided by the Health Services and Delivery Research programme of the National Institute for Health Research.
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Affiliation(s)
- Bruce Guthrie
- Quality, Safety and Informatics Research Group, Population Health Sciences Division, Medical Research Institute, University of Dundee, Dundee, UK
| | - Ning Yu
- Tayside Medicine Unit, NHS Tayside, Dundee, UK
- Institute of Epidemiology and Health, Faculty of Population Health Sciences, University College London, London, UK
| | - Douglas Murphy
- Quality, Safety and Informatics Research Group, Population Health Sciences Division, Medical Research Institute, University of Dundee, Dundee, UK
| | - Peter T Donnan
- Quality, Safety and Informatics Research Group, Population Health Sciences Division, Medical Research Institute, University of Dundee, Dundee, UK
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Pain medication management of musculoskeletal conditions at first presentation in primary care: analysis of routinely collected medical record data. BMC Musculoskelet Disord 2014; 15:418. [PMID: 25492581 DOI: 10.1186/1471-2474-15-418] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2014] [Accepted: 12/05/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Primary care pharmacological management of new musculoskeletal conditions is not consistent, despite guidelines which recommend prescribing basic analgesics before higher potency medications such as opioids or non-steroidal inflammatory drugs (NSAIDs).The objective was to describe pharmacological management of new musculoskeletal conditions and determine patient characteristics associated with type of medication prescribed. METHODS The study was set within a UK general practice database, the Consultations in Primary Care Archive (CiPCA). Patients aged 15 plus who had consulted for a musculoskeletal condition in 2006 but without a musculoskeletal consultation or analgesic prescription in the previous 12 months were identified from 12 general practices. Analgesic prescriptions within two weeks of first consultation were identified. The association of socio-demographic and clinical factors with receiving any analgesic prescription, and with strength of analgesic, were evaluated. RESULTS 3236 patients consulted for a new musculoskeletal problem. 42% received a prescribed pain medication at that time. Of these, 47% were prescribed an NSAID, 24% basic analgesics, 18% moderate strength analgesics, and 11% strong analgesics. Increasing age was associated with an analgesic prescription but reduced likelihood of a prescription of NSAIDs or strong analgesics. Those in less deprived areas were less likely than those in the most deprived areas to be prescribed analgesics (odds ratio 0.69; 95% CI 0.55, 0.86). Those without comorbidity were more likely to be prescribed NSAIDs (relative risk ratios (RRR) compared to basic analgesics 1.89; 95% CI 0.96, 3.73). Prescribing of stronger analgesics was related to prior history of analgesic medication (for example, moderate analgesics RRR 1.88; 95% CI 1.11, 3.10). CONCLUSION Over half of patients were not prescribed analgesia for a new episode of a musculoskeletal condition, but those that were often received NSAIDs. Analgesic choice appears multifactorial, but associations with age, comorbidity, and prior medication history suggest partial use of guidelines.
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Edwards JJ, Jordan KP, Peat G, Bedson J, Croft PR, Hay EM, Dziedzic KS. Quality of care for OA: the effect of a point-of-care consultation recording template. Rheumatology (Oxford) 2014; 54:844-53. [PMID: 25336538 PMCID: PMC4416084 DOI: 10.1093/rheumatology/keu411] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2014] [Indexed: 01/09/2023] Open
Abstract
Objective. The aims of this study were to determine the feasibility of introducing a computerized template for identifying quality of care during an OA consultation, describe quality of OA care in practices in which the template was introduced and assess the effect of the template on routinely recorded clinician behaviour in those practices. Methods. A computerized template to assist the recording of care in consultations for patients with OA was installed in eight general practices. Eligible patients were those ≥45 years of age consulting for clinical OA during a 6 month period. The main outcomes were frequency of template triggering, achievement of quality indicators during the consultation (assessment of pain and function, assessment for first-line analgesics, provision of information, exercise advice, consideration of physiotherapy referral, weight loss advice) and change in routinely recorded clinician behaviour (diagnostic coding, prescribing, referral, use of radiography, weight records) compared with the 12 months prior to template installation. Results. The template was triggered for 1730 patients. Achievement of indicators ranged from 36% (for consideration of physiotherapy referral) to 63% (for pain assessment), with substantial variability between clinicians. There was an increase in prescription of recommended first-line analgesics following the template installation: paracetamol [odds ratio (OR) 1.49 (95% CI 1.22, 1.82) compared with pre-template] and topical NSAIDs [OR 1.95 (95% CI 1.61, 2.35)]. Conclusion. This new template is a feasible tool for capturing data during OA consultations to aid assessment of quality of care. It was associated with significant improvements in recommended care processes. However, strategies are needed to ensure consistent approaches between clinicians. Trial registration.http://www.controlled-trials.com/ISRCTN06984617/mosaics.
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Affiliation(s)
- John J Edwards
- Arthritis Research UK Primary Care Centre, Research Institute for Primary Care and Health Sciences, Keele University, UK
| | - Kelvin P Jordan
- Arthritis Research UK Primary Care Centre, Research Institute for Primary Care and Health Sciences, Keele University, UK
| | - George Peat
- Arthritis Research UK Primary Care Centre, Research Institute for Primary Care and Health Sciences, Keele University, UK
| | - John Bedson
- Arthritis Research UK Primary Care Centre, Research Institute for Primary Care and Health Sciences, Keele University, UK
| | - Peter R Croft
- Arthritis Research UK Primary Care Centre, Research Institute for Primary Care and Health Sciences, Keele University, UK
| | - Elaine M Hay
- Arthritis Research UK Primary Care Centre, Research Institute for Primary Care and Health Sciences, Keele University, UK
| | - Krysia S Dziedzic
- Arthritis Research UK Primary Care Centre, Research Institute for Primary Care and Health Sciences, Keele University, UK
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Koffeman AR, Valkhoff VE, Jong GW, Warlé-van Herwaarden MF, Bindels PJ, Sturkenboom MC, Luijsterburg PA, Bierma-Zeinstra SM. Ischaemic cardiovascular risk and prescription of non-steroidal anti-inflammatory drugs for musculoskeletal complaints. Scand J Prim Health Care 2014; 32:90-8. [PMID: 24931511 PMCID: PMC4075023 DOI: 10.3109/02813432.2014.929810] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE To determine the influence of ischaemic cardiovascular (CV) risk on prescription of non-steroidal anti-inflammatory drugs (NSAIDs) by general practitioners (GPs) in patients with musculoskeletal complaints. DESIGN Cohort study. SETTING A healthcare database containing the electronic GP medical records of over one million patients throughout the Netherlands. PATIENTS A total of 474 201 adults consulting their GP with a new musculoskeletal complaint between 2000 and 2010. Patients were considered at high CV risk if they had a history of myocardial infarction, angina pectoris, stroke, transient ischaemic attack, or peripheral arterial disease, and at low CV risk if they had no CV risk factors. MAIN OUTCOME MEASURES Frequency of prescription of non-selective (ns)NSAIDs and selective cyclooxygenase-2 inhibitors (coxibs). RESULTS Overall, 24.4% of patients were prescribed an nsNSAID and 1.4% a coxib. Of the 41,483 patients with a high CV risk, 19.9% received an nsNSAID and 2.2% a coxib. These patients were more likely to be prescribed a coxib than patients with a low CV risk (OR 1.9, 95% CI 1.8-2.0). Prescription of nsNSAIDs decreased over time in all risk groups and was lower in patients with a high CV risk than in patients with a low CV risk (OR 0.8, 95% CI 0.7-0.8). CONCLUSION Overall, patients with a high CV risk were less likely to be prescribed an NSAID for musculoskeletal complaints than patients with a low CV risk. Nevertheless, one in five high CV risk patients received an NSAID, indicating that there is still room for improvement.
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Affiliation(s)
- Aafke R Koffeman
- Department of General Practice, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Vera E Valkhoff
- Department of Medical Informatics, Erasmus MC University Medical Center, Rotterdam, The Netherlands
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Geert W't Jong
- Department of Medical Informatics, Erasmus MC University Medical Center, Rotterdam, The Netherlands
- Department of Paediatrics & Child Health, University of Manitoba, Winnipeg MB, Canada
| | | | - Patrick Je Bindels
- Department of General Practice, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Miriam Cjm Sturkenboom
- Department of Medical Informatics, Erasmus MC University Medical Center, Rotterdam, The Netherlands
- Department of Epidemiology, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Pim Aj Luijsterburg
- Department of General Practice, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Sita Ma Bierma-Zeinstra
- Department of General Practice, Erasmus MC University Medical Center, Rotterdam, The Netherlands
- Department of Orthopaedic Surgery, Erasmus MC University Medical Center, Rotterdam, The Netherlands
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Ruscitto A, Smith BH, Guthrie B. Changes in opioid and other analgesic use 1995-2010: repeated cross-sectional analysis of dispensed prescribing for a large geographical population in Scotland. Eur J Pain 2014; 19:59-66. [PMID: 24807782 DOI: 10.1002/ejp.520] [Citation(s) in RCA: 86] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/06/2014] [Indexed: 01/23/2023]
Abstract
BACKGROUND Despite recent concerns about increasing rates of analgesic prescribing, detailed epidemiological studies are lacking. We identified and described changes in the pattern of community-dispensed prescriptions to the Tayside population, Scotland, between 31st March 1995 (n = 301,020) and 31st March 2010 (n = 311,881). METHODS Repeated cross-sectional analysis of patient-level population data on dispensed analgesics, stratified by sociodemographic variables; logistic regression to identify factors associated with strong opioid dispensing in 2010. RESULTS The proportion of people currently dispensed any analgesic increased in 2010 (17.9%) compared with 1995 (15.7%). This increase was not equal across drug classes, with paracetamol, opioids and gabapentin/pregabalin showing an increase, but others showing a decrease. Weak opioids were less commonly dispensed in 2010 (8.2% vs. 8.4%) but dispensing of strong opioids increased 18-fold (3.6% vs. 0.2%), including a five-fold increase of morphine, fentanyl or oxycodone (0.75% vs. 0.15%). People receiving more non-analgesic drugs (odds ratio 20.7 if dispensed >14 non-analgesic medications vs. those dispensed <4) and those living in more deprived areas (OR 1.63 most deprived vs. most affluent) were more likely to receive a strong opioid in 2010. CONCLUSIONS Analgesic use rose modestly between 1995 and 2010, but with larger changes within individual classes, only partly reflecting evidence-based guidance. Dispensing of strong opioids increased dramatically, largely driven by tramadol, although other strong opioids tripled. Polypharmacy and socio-economic deprivation were strongly associated with strong opioid use. Research is needed to establish the causes, benefits and harms of the increase in analgesic, and especially strong opioid use.
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Affiliation(s)
- A Ruscitto
- Ninewells Hospital and Medical School, University of Dundee, Dundee, Scotland
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Osteoarthritis and the rule of halves. Osteoarthritis Cartilage 2014; 22:535-9. [PMID: 24565953 PMCID: PMC3988991 DOI: 10.1016/j.joca.2014.02.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2013] [Revised: 12/20/2013] [Accepted: 02/14/2014] [Indexed: 02/02/2023]
Abstract
BACKGROUND Symptomatic osteoarthritis poses a major challenge to primary health care but no studies have related accessing primary care ('detection'), receiving recommended treatments ('treatment'), and achieving adequate control ('control'). OBJECTIVE To provide estimates of detection, treatment, and control within a single population adapting the approach used to determine a Rule of Halves for other long-term conditions. SETTING General population. PARTICIPANTS 400 adults aged 50+ years with prevalent symptomatic knee osteoarthritis. DESIGN Prospective cohort with baseline questionnaire, clinical assessment, and plain radiographs, and questionnaire follow-up at 18 and 36 months and linkage to primary care medical records. OUTCOME MEASURES 'Detection' was defined as at least one musculoskeletal knee-related GP consultation between baseline and 36 months. 'Treatment' was self-reported use of at least one recommended treatment or physiotherapy/hospital specialist referral for their knee problem at all three measurement points. Pain was 'controlled' if characteristic pain intensity <5 out of 10 on at least two occasions. RESULTS In 221 cases (55.3%; 95%CI: 50.4, 60.1) there was evidence that the current problem had been detected in general practice. Of those detected, 164 (74.2% (68.4, 80.0)) were receiving one or more of the recommended treatments at all three measurement points. Of those detected and treated, 45 (27.4% (20.5, 34.3)) had symptoms under control on at least two occasions. Using narrower definitions resulted in substantially lower estimates. CONCLUSION Osteoarthritis care does not conform to a Rule of Halves. Symptom control is low among those accessing health care and receiving treatment.
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Lacey RJ, Jordan KP, Croft PR. Does attrition during follow-up of a population cohort study inevitably lead to biased estimates of health status? PLoS One 2013; 8:e83948. [PMID: 24386313 PMCID: PMC3875525 DOI: 10.1371/journal.pone.0083948] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2013] [Accepted: 11/11/2013] [Indexed: 11/18/2022] Open
Abstract
Attrition is a potential source of bias in cohort studies. Although attrition may be inevitable in cohort studies of older people, there is little empirical evidence as to whether bias due to such attrition is also inevitable. Anonymised primary care data, routinely collected in clinical practice and independent of any cohort research study, represents an ideal unselected comparison dataset with which to compare primary care data from consenting responders to a cohort study. Our objective was to use this method as a novel means to assess if (i) responders at follow-up stages in a cohort study remain representative of responders at baseline and (ii) attrition biases estimates of longitudinal associations. We compared primary care consultation morbidities and prescription prevalences among circa 32,000 patients aged 50+ who contribute to an anonymised general practice database (Consultations in Primary Care Archive (CiPCA)) with those from patients aged 50+ in the North Staffordshire Osteoarthritis Project (NorStOP) cohort, United Kingdom (2002–2008; n = 16,159). 8,197 (51%) persons responded to the NorStOP baseline survey and consented to medical record review. 5,121 and 3,311 responded at 3- and 6-year follow-ups. Differences in consulting prevalence of non-musculoskeletal morbidities between NorStOP responders and CiPCA comparison population did not increase over the two follow-up points except for ischaemic heart disease. Differences observed at baseline for osteoarthritis-related consultations were generally unchanged at the two follow-ups (standardised prevalence ratios for osteoarthritis (1.09–1.13) and joint pain (1.12–1.23)). Age and gender adjusted associations between baseline consultation for chronic morbidity and future new osteoarthritis and related consultations were similar in CiPCA (adjusted Hazard Ratio: 1.40; 95% Confidence Interval: 1.34,1.47) and NorStOP 6-year responders (1.32; 1.15,1.51). There was little evidence that responders at follow-ups represented any further selection bias to that present at baseline. Attrition in cohort studies of older people does not inevitably indicate bias.
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Affiliation(s)
- Rosie J. Lacey
- Research Institute for Primary Care & Health Sciences, Keele University, Keele, Staffordshire, United Kingdom
- * E-mail:
| | - Kelvin P. Jordan
- Research Institute for Primary Care & Health Sciences, Keele University, Keele, Staffordshire, United Kingdom
| | - Peter R. Croft
- Research Institute for Primary Care & Health Sciences, Keele University, Keele, Staffordshire, United Kingdom
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Ashworth J, Green DJ, Dunn KM, Jordan KP. Opioid use among low back pain patients in primary care: Is opioid prescription associated with disability at 6-month follow-up? Pain 2013; 154:1038-44. [PMID: 23688575 PMCID: PMC4250559 DOI: 10.1016/j.pain.2013.03.011] [Citation(s) in RCA: 75] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2012] [Revised: 12/17/2012] [Accepted: 03/07/2013] [Indexed: 11/30/2022]
Abstract
Opioid prescribing for chronic noncancer pain is increasing, but there is limited knowledge about longer-term outcomes of people receiving opioids for conditions such as back pain. This study aimed to explore the relationship between prescribed opioids and disability among patients consulting in primary care with back pain. A total of 715 participants from a prospective cohort study, who gave consent for review of medical and prescribing records and completed baseline and 6 month follow-up questionnaires, were included. Opioid prescription data were obtained from electronic prescribing records, and morphine equivalent doses were calculated. The primary outcome was disability (Roland-Morris Disability Questionnaire [RMDQ]) at 6 months. Multivariable linear regression was used to examine the association between opioid prescription at baseline and RMDQ score at 6 months. Analyses were adjusted for potential confounders using propensity scores reflecting the probability of opioid prescription given baseline characteristics. In the baseline period, 234 participants (32.7%) were prescribed opioids. In the final multivariable analysis, opioid prescription at baseline was significantly associated with higher disability at 6-month follow-up (P < .022), but the magnitude of this effect was small, with a mean RMDQ score of 1.18 (95% confidence interval: 0.17 to 2.19) points higher among those prescribed opioids compared to those who were not. Our findings indicate that even after adjusting for a substantial number of potential confounders, opioids were associated with slightly worse functioning in back pain patients at 6-month follow-up. Further research may help us to understand the mechanisms underlying these findings and inform clinical decisions regarding the usefulness of opioids for back pain.
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Affiliation(s)
- Julie Ashworth
- Arthritis Research UK Primary Care Centre, Keele University, Staffordshire, UK.
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