Use and prescription appropriateness of drugs for peptic ulcer and gastrooesophageal reflux disease in hospitalized older people

PURPOSE

The aims of this study were to assess the prevalence of use and prescription appropriateness of drugs for peptic ulcer and gastrooesophageal reflux disease (GERD) at hospital admission and discharge.

METHODS

Patients aged 65 years or more hospitalized from 2010 to 2016 in 101 Italian internal medicine and geriatric wards in the context of the REPOSI register were scrutinized to assess if they were prescribed with drugs for peptic ulcer and GERD at hospital admission and discharge. Appropriateness of prescription was assessed considering the presence of specific conditions (i.e., history of peptic ulcer or gastrointestinal hemorrhages, advanced age, Helicobacter Pylori) or gastro-toxic drug combinations, according to the criteria provided by the reimbursement rules of the Agenzia Italiana del Farmaco (NOTA 1 and 48).

RESULTS

Among 4715 enrolled patients, 3899 were discharged alive. At hospital discharge, 2412 (61.9%, 95%CI: 60.3-63.4%) patients were prescribed with drugs for peptic ulcer and GERD, a 12% of increase from hospital admission. Almost half of the patients (N = 1776, 45.6%, 95%CI: 44.0-47.1%) were inappropriately prescribed or not prescribed: among the drugs for peptic ulcer and GERD users, about 60% (1444/2412) were overprescribed, and among nonusers, 22% (332/1487) were underprescribed. Among patients newly prescribed at hospital discharge, 60% (392/668) were inappropriately prescribed. The appropriateness of drugs for peptic ulcer and GERD therapy decreased by 3% from hospital admission to discharge.

CONCLUSIONS

Hospitalization missed the opportunity to improve the quality of prescription of this class of drug.

Inappropriate prescription of benzodiazepines in acutely hospitalized older patients

Benzodiazepines (BDZs) are widely prescribed in older people. The aims of the study are to assess the prevalence of inappropriate prescription of BZDs and the associated factors in acutely hospitalized older patients. Patients aged 65 years or more hospitalized from 2010 to 2017 in more than 100 Italian internal medicine and geriatric wards in the frame of the REPOSI register were included if prescribed with BDZs at hospital admission or discharge. Appropriateness of prescription was assessed according to the 2015 Beers criteria and their modified French and German versions. Among 4681 patients discharged from hospital, 15% (N = 710) were discharged with BDZs, and 62% of them (N = 441, 95% CI: 58.5%-65.6%) were inappropriately prescribed, being prescribed with BDZ to be always avoided in the elderly (45%), at higher doses than recommended (31%) or with no appropriate clinical conditions (19%). From admission to discharge the prevalence of inappropriate BDZ prescription decreased by 4%, but 62% of patients inappropriately prescribed at admission were still inappropriately prescribed at discharge. Among the 179 patients first prescribed at the time of discharge, half were inappropriately prescribed. Being female (OR 1.32, 95%CI 0.95-1.85), enrolled in REPOSI during the years 2016 and 2017 (OR 1.94, 95%CI 1.10-3.39; OR 1.57, 95%CI 0.95-2.58) and living in nursing homes (OR 2.04, 95%CI 0.95-4.37) were associated with an increased risk to be inappropriately prescribed. This study shows a high prevalence of inappropriate use of BDZ in acutely hospitalized older patients both at hospital admission and discharge.

Antibiotic use and associated factors in a large sample of hospitalised older people

OBJECTIVES

The aims of this study were to assess (i) the prevalence of antibiotic use, (ii) factors associated with their use and (iii) the association with in-hospital mortality in a large sample of hospitalised older people in Italy.

METHODS

Data were obtained from the 2010-2017 REPOSI register held in more than 100 internal medicine and geriatric wards in Italy. Patients aged ≥65 years with at least one antibiotic prescription during their hospitalisation were selected. Multivariable logistic regression models were used to determine factors associated with antibiotic use.

RESULTS

A total of 5442 older patients were included in the analysis, of whom 2786 (51.2%) were prescribed antibiotics during their hospitalisation. The most frequently prescribed antibiotic class was β- lactams, accounting for 50% of the total prescriptions. Poor physical independence, corticosteroid use and being hospitalised in Northern Italy were factors associated with a higher likelihood of being prescribed antibiotics. Antibiotic use was associated with an increased risk of in-hospital mortality (odds ratio=2.52, 95% confidence interval 1.82-3.48) also when accounting for factors associated with their use.

CONCLUSION

Hospitalised older people are often prescribed antibiotics. Factors related to poor physical independence and corticosteroid use are associated with increased antibiotic use. Being prescribed antibiotics is also associated with an increased risk of in-hospital death. These results demand the implementation of specific stewardship programmes to improve the correct use of antibiotics in hospital settings and to reduce the risk of antimicrobial resistance.

Implementation of the Frailty Index in hospitalized older patients: Results from the REPOSI register

BACKGROUND

Frailty is a state of increased vulnerability to stressors, associated to poor health outcomes. The aim of this study was to design and introduce a Frailty Index (FI; according to the age-related accumulation of deficit model) in a large cohort of hospitalized older persons, in order to benefit from its capacity to comprehensively weight the risk profile of the individual.

METHODS

Patients aged 65 and older enrolled in the REPOSI register from 2010 to 2016 were considered in the present analyses. Variables recorded at the hospital admission (including socio-demographic, physical, cognitive, functional and clinical factors) were used to compute the FI. The prognostic impact of the FI on in-hospital and 12-month mortality was assessed.

RESULTS

Among the 4488 patients of the REPOSI register, 3847 were considered eligible for a 34-item FI computation. The median FI in the sample was 0.27 (interquartile range 0.21-0.37). The FI was significantly predictive of both in-hospital (OR 1.61, 95%CI 1.38-1.87) and overall (HR 1.46, 95%CI 1.32-1.62) mortality, also after adjustment for age and sex.

CONCLUSIONS

The FI confirms its strong predictive value for negative outcomes. Its implementation in cohort studies (including those conducted in the hospital setting) may provide useful information for better weighting the complexity of the older person and accordingly design personalized interventions.

Abstract P2-06-07: Risk of metastases after ipsilateral breast tumour recurrence changes overtime according to patient and tumour characteristics: Implications for treatment

To evaluate the risk of systemic disease of early breast cancer (EBC) patients undergoing breast conservative surgery between 1970 - 2000 and experiencing ipsilateral breast tumour recurrence (IBTR). Patients and Methods The study population included EBC patients randomly assigned onto 5 Milan prospective trials (n= 915) or comparably treated outside clinical trials (n= 1060) with quadrantectomy followed by radiotherapy and with known primary tumor characteristics. Multivariable regression analysis was performed via the piecewise exponential. The model accounts other than known prognostic factors, including age, menopausal status, pathologic size, nodal status and time dependent effect for estrogen receptor (ER) for the IBTR occurrence as time dependent covariate (i.e. switching from 0 to 1 at the time of surgery for IBTR). Also the new time scale induced by IBTR occurrence, namely time elapsed since surgery for IBTR to the end-point of interest, was accounted for in the model.

Results Median follow-up was 124 months (IQ Range 96.6 – 179). At the time of analysis, 504 patients were died, 470 presented with systemic disease and 150 with IBTR as first breast cancer event. IBTR was associated with a high risk of systemic disease. This risk was dependent on primary tumor characteristics, including T size, 2 versus 1 (HR 1.79 95% CI 1.46 – 2.21), and nodal status, N1 versus N0 (HR 1.61, 95% CI 1.32 – 1.98), and N2 versus N0 (HR 3.91, 95% CI 3.13 – 4.89). Of note, ER-negative cohort had a slightly earlier and higher hazard of events overtime compared with ER-positive cohort, which, instead, presented higher hazard estimates over the long follow-up period. The most important finding concerned the new timescale induced by IBTR occurrence that revealed to have definite prognostic value, and suggest that patients with IBTR as compared with patients with no IBTR have a sudden and at least 5-fold increase of risk of systemic disease within 2 years following second surgery; of note, this risk decreases thereafter, though it never desappears. Conclusion Breast cancer patients experiencing IBTR are at increased risk of systemic disease. This risk changes overtime and is different according to initial patient and primary tumor characteristics, and hormonal receptor status. The definition of different patterns of BC recurrence can improve BC care through surveillance guidelines and can guide the design of tailored clinical studies.

Citation Format: Gennaro M, Di Cosimo S, Ardoino I, Veneroni S, Mariani L, de Braud F, Daidone MG, Biganzoli E, Demicheli R. Risk of metastases after ipsilateral breast tumour recurrence changes overtime according to patient and tumour characteristics: Implications for treatment [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P2-06-07.

Risk factors and epidemiology of Acinetobacter baumannii infections in a university hospital in Northern Italy: A case-control study

BACKGROUND

Acinetobacter baumannii has emerged as a major cause of outbreaks of hospital-associated infections with increased morbidity and mortality among those affected.

METHODS

We performed a 1:1 matched case-control study involving 68 cases in a teaching hospital in Northern Italy. Risk factors included general health conditions, comorbidities, diagnostic and therapeutic procedures, and antibiotic therapies. A multiple correspondence analysis (MCA) was performed to highlight possible association patterns among risk factors. After this, a conditional logistic regression model was applied.

RESULTS

The combined results of the MCA and univariate regression models suggest that invasive procedures performed before intensive care unit admission, in particular bronchoscopy (odds ratio, 48.06) and oxygen therapy (odds ratio, 2.11), are associated with development of an infection. Malnutrition or obesity, lack of self-sufficiency, and severe liver diseases also proved to be significantly associated with infection. When analyzing antibiotic therapies, both the number of molecules administered and duration of therapy were significantly associated.

CONCLUSIONS

Early recognition of patients at high risk, environmental hygiene control measures, appropriate antibiotic prescriptions, especially regarding carbapenems, and high-quality training of health care workers in all hospital departments are all key aspects for prevention and control of Acinetobacter infection. Further studies are needed to investigate the role of antibiotics on microbial competition dynamics in relation to multidrug-resistant outbreaks.

Drug survival and reasons for discontinuation of the first course of biological therapy in 301 juvenile idiopathic arthritis patients

The objective of this study was to determine long-term effectiveness and safety of 1st biological treatment (BT) in a cohort of 301 juvenile idiopathic arthritis (JIA) patients (pts), non-responders to disease-modifying antirheumatic drugs (DMARDs), in terms of drug survival (continuation rate on therapy) and to identify the baseline predictors of treatment discontinuation. Each JIA pt enrolled in BT is prospectively assessed at the start of treatment and then every 2 months for the evaluation of safety and efficacy according to ACR-Pedi30 criteria. All clinical charts of pts who started a BT between November 1999 and July 2010 have been reviewed. Survival analysis methods suitable for competing risks were used to study time to drug discontinuation due to disease control (defined according to Wallace criteria) or failure [adverse event (AE), lack of efficacy (LaE) or loss of efficacy (LoE) according ACR-Pedi30]. A number of 301 JIA pts, non-responders or intolerant to DMARDs and treated with one or more cycles of BT, were identified. Median disease duration, from onset to the beginning of 1st BT, was 7.8 years (interquartil range 2.21-15.1). In total, there were 294 1st corses with anti-TNF agents, 5 with abatacept and 2 with anakinra. A number of 298 pts were included in the analysis for drug discontinuation (3 pts with no follow-up data after their first dose of BT were excluded). The median follow-up on treatment, before discontinuation due to every cause, was 53.7 months (range 0.45-124.45). One hundred and sixty-five pts discontinued BT: 27 due to disease control, 135 because of failure (78 AEs, 12 LaE and 45 LoE), 3 pts temporarily stopped for pregnancy. Among 135 pts who discontinued for failure, 117 switched to a 2nd BT. Among 27 pts who discontinued due to remission, 13 pts restarted on BT for relapse of disease activity (10 pts restarted with the same BT, 3 switched to a different one). Predictors of discontinuation due to AE were female gender (P=0.01) and longer disease duration (P=0.02). Predictors of discontinuation due to LaE or LoE were systemic onset and polyarthritis FR positive (vs other JIA subtypes) (P<0.05) and use of mAb-anti-TNF (vs sTNFR) (P=0.02). Predictors of discontinuation due to inactive disease were male gender and shorter disease duration (P<0.05). Although only few pts discontinued BT due to a complete and persistent disease control, the majority of them remained on BT for a long time, suggesting that in our cohort of JIA pts, affected by a severe long lasting refractory disease, BT was globally well tolerate and efficacious in controlling the disease.