Mandatory nonmedical switching from originator to biosimilar infliximab in patients with inflammatory arthritis and psoriasis in British Columbia: a cohort study

BACKGROUND

In 2019, British Columbia's public drug plan, PharmaCare, was the first in Canada to implement a nonmedical switching policy from originator infliximab to its biosimilar, for patients with inflammatory arthritis or psoriasis. We aimed to detect signals of impact on health services utilization during the first year of policy implementation and to provide early data to policy-makers.

METHODS

We constructed cohorts of users of originator infliximab: 3 historical cohorts (2016-2018) and 1 policy cohort (2019). We extracted data from BC Ministry of Health databases from 2015 to 2020, as we followed each cohort for 365 days from May 27 of each cohort's respective year. We excluded patients with gastrointestinal conditions and those not covered by PharmaCare. We examined the cumulative incidence of infliximab prescription refills, switching to other biologic drugs and use of additional health services. A log-likelihood ratio of 1.96 compared with the null hypothesis was used as the threshold for differences between the policy cohort and the historical cohorts.

RESULTS

The study included a total of 572 unique patients: 520 in the 2016 historical cohort, 461 in the 2017 historical cohort, 423 in the 2018 historical cohort and 377 in the policy cohort (with some patients included in multiple cohorts; 335 [58.6%] were included in all 4 cohorts). During months 8 and 9 of follow-up, a transient signal was observed in infliximab refills (7.2% decrease in refilling infliximab for the fourth time for the policy cohort, log-likelihood ratio > 1.96). An anticipated increase in visits to specialists was observed from month 4 forward (15.0%, log-likelihood ratio > 1.96). No signal was observed for increased use of other health services (log-likelihood ratio < 1.96).

INTERPRETATION

Early monitoring did not detect signals of negative impacts on health services use during the first year of the policy. Detailed, longer-term cohort studies and hypothesis-testing methods could provide additional assurance about the safety of the policy.

Web search popularity, publicity, and utilization of direct oral anticoagulants in the United States, 2008-2018: A STROBE-compliant study

We aimed to study the changing popularity of oral anticoagulants and the potential association between media coverage and real-world utilization practice, using time series analysis.In this STROBE-compliant study, we used Google Trends data to study public interest for direct oral anticoagulants (DOACs) (dabigatran, rivaroxaban, apixaban, and edoxaban) and warfarin in the United States (10-year coverage, beginning July 1st, 2008 ending June 30th, 2018). We validated our findings on a sample of 50 consecutive datasets (accumulated between July 6th, 2018 and October 19th, 2018), using the same search criteria. We used the LexisNexis Academic database to quantify monthly media coverage for DOACs and explored its association with interest by the public, using the cross-correlation coefficient function. Finally, we studied the association between public interest and real-world utilization data, including published US-wide data on ambulatory anticoagulation visits.The approval of dabigatran in 2010 marked an increasing public interest for DOACs. Dabigatran exhibited a steep rise early after Food and Drug Administration approval that peaks in 2011, to be surpassed sequentially by rivaroxaban (2012) and apixaban (2014). Apixaban has outperformed its competitors in popularity since mid-2017, and, by the end of the observation period, was close to warfarin that is on first place. Media coverage was low before approval of the first oral DOAC (dabigatran), increased thereafter (median 13 news articles per month vs 64, P < .001), with peaks on the approval dates (81 vs 48, P = .003). Media coverage had a weak immediate impact on DOACs public interest and public interest patterns preceded changes in ambulatory anticoagulation visits by up to 5 months.For a long-run observation period, a single Google Trends search will suffice to produce robust estimations of the relative popularity between treatment options, such as oral anticoagulants. Media coverage has limited immediate impact and relative public interest is a potential lead indicator of changes in actual utilization.

Antibiotic prescriptions in Italian hospitalised children after serial point prevalence surveys (or pointless prevalence surveys): has anything actually changed over the years?

BACKGROUND

Point prevalence surveys have been used in several studies to provide immediate and easily comparable information about antibiotic use and showed that about one third of hospitalised children had on ongoing antimicrobial prescription during their hospital admission. The aim of this study, as part of the Global Antimicrobial Resistance, Prescribing and Efficacy in Neonates and Children project, is to describe antimicrobial prescriptions among hospitalised children in four tertiary care hospitals in Italy to show if something has changed over the years.

METHODS

Four tertiary care Italian's hospitals joined three Point Prevalence Surveys (PPSs) in three different period of the year. All children under 18 years of age with an ongoing antimicrobial prescription, admitted on the participating wards at 8 o'clock in the morning of the selecting day were enrolled.

RESULTS

A total of 1412 patients (475 neonates and 937 children) were admitted in the days of three PPSs. Overall, among the total admitted patients, 565 patients (40%) had an ongoing antimicrobial prescription in the days of the survey A total of 718 antibiotics were administered in the 485 admitted children and 133 in neonates. The most common indications for antibiotic therapy in children was Lower respiratory tract infections (244/718, 34%), while in neonates were prophylaxis for medical problems (35/133, 26.3%), newborn prophylaxis for newborn risk factors (29/133, 21.8%) and prophylaxis for surgical disease (15/133, 11.3%).

CONCLUSIONS

Based on our results, it appears that nothing has changed since the last PPS and that the quality improved targets, underlyined in previous studies, are always the same. Serial PPSs can be part of AMS strategies but they are not sufficient alone to produce changes in clinical practice.

Discontinuation, persistence and adherence to subcutaneous biologics delivered via a homecare route to Scottish adults with rheumatic diseases: a retrospective study

OBJECTIVES

To understand patterns of subcutaneous (SC) biologics use over time in adults with inflammatory rheumatic musculoskeletal diseases receiving a homecare delivery service.

DESIGN

Retrospective cohort.

SETTING

Patients in secondary care receiving SC biologics in the largest Scottish Health Board.

PARTICIPANTS

A new bespoke cohort was created from routine data gathered as part of a health board Homecare Service Database. Patients over 18 years who received a supply of SC biologic from January 2012 to May 2015 with a diagnosis for rheumatoid arthritis (RA), psoriatic arthritis (PsA) or ankylosing spondylitis (AS) were included.

OUTCOMES MEASURED

A standardised framework was applied by measuring discontinuation rates, persistence using Kaplan-Meier analysis and Cox regression and adherence using medication refill adherence (MRA) and compliance rate (CR).

RESULTS

751 patients were identified (AS: 105, PsA: 227, RA: 419) of whom 89.3% had more than one biologic delivery (median days' follow-up: AS: 494; PsA: 544; RA: 529) and 83.2% did not switch biologic. For all conditions, approximately half were persistent on their index biologic (52% AS, 54% PsA, 48%RA). Of patients who discontinued treatment, the majority reinitiated with the same biologic (19% AS, 18% PsA and 21% RA). Overall adherence during the period of treatment was over 80% when calculated using MRA (median %MRA: AS: 84.0%, PsA: 85.0%, RA: 82.4%) or CR (median %CR: AS: 96.6%, PsA: 97%, RA: 96.6%).

CONCLUSION

Use of linked routine data is a sustainable pathway to enable ongoing evaluation of biologics use. A more consistent approach to studying use (discontinuation, persistence and adherence metrics) should be adopted to enable comparability of studies.

Practices in the Usage and Reconstitution of Poly-L-Lactic Acid

BACKGROUND: Poly-L-lactic acid (PLLA) is increasingly used for a range of indications, from HIV lipodystrophy to gluteal augmentation; however, there is no clear consensus on appropriate product preparation and use. OBJECTIVE: To establish current practices for PLLA reconstitution and usage in the USA. METHODS AND MATERIALS: A 19-question survey pertaining to the reconstitution and use of PLLA was distributed to members of the American Board of Cosmetic Surgery and American Board of Facial Cosmetic Surgery and at several cosmetic conferences. 410 questionnaires were returned anonymously over a 3-month period. The results were collated and analyzed. RESULTS: The commonest indication for PLLA was HIV lipodystrophy (46.8%), followed by gluteal augmentation (42.4%). For the face, the majority used a dilution of 9-10 mL (60.4%). For the gluteal region, the majority used a dilution greater than 21 mL (51.3%). Most respondents reconstituted PLLA in sterile water (59.8%) more than 21 hours before use (51.0%) and added lidocaine to the solution (94.7%). Most physicians used topical anesthetic cream (83.2%), manual agitation (85.8%) and recommended self-massage post-treatment (99.6%). CONCLUSION: There is considerable variation in PLLA reconstitution and use. Further well-designed studies are needed to establish the safest, most effective ways to use this product. J Drugs Dermatol. 2019;18(9):880-886.

Variability in the community consumption of antibiotics: a problem in Europe, Spain and Asturias

Increasing bacterial resistance is strictly correlated to the increasing use of antibiotics, currently constituting a public health problem. The aim of this study was to describe the consumption of antibiotics in Asturias, an autonomous community in northwestern Spain, and compare the results obtained with data from elsewhere in Spain and other European countries. A descriptive study was carried out on the use of antibacterial drugs for systemic use, ATC code J01 in Asturias in 2011-2015. Data were obtained from the prescription-billing information system charged to the Health Service of Asturias. The consumption data are expressed in daily doses per 1,000 inhabitants and day (DHD), and number of packages per thousand inhabitants per day. The average weighted consumption of antibiotics for systemic use in the Asturian community was 26.23 daily doses per 1000 inhabitants per day (DHD) in 2015. This figure was higher than that of the EU/EEA population, which was 22.4 DHD, and that of the whole of Spain at 22.2 DHD. There is a wide variability in consumption among the different areas of the Asturian region. This variability is common to the rest of the country and Europe. It can be explained by the influence of the data used in the indicators and by the variability in medical practice. Priority should be given to homologating consumer-monitoring information systems and implementing national strategies aimed at providing more information to medical practitioners, encouraging the appropriate use of antibiotics so as to reduce variability, consumption and resistance.

Assessment of vancomycin utilization among Lebanese hospitals

Objectives:

To assess the appropriateness of vancomycin dosing and monitoring at Lebanese hospitals.

Methods:

This was a multicenter retrospective study conducted at 3 Lebanese hospitals between January and March 2018. Patients 18 years of age and older treated with vancomycin for a systemic infection or prophylaxis were eligible for study enrollment. Consistency with the Infectious Diseases Society of America guidelines was evaluated to determine whether the dose of vancomycin was appropriate, as well as for the time of trough measurement, and the target concentration obtained.

Results:

From a total of 120 patients who met the inclusion criteria, only 11 (12%) were given the appropriate maintenance dose of vancomycin with respect to actual body weight. The trough levels were monitored for 67 (55.8%) patients, with 20 (29.9%) of these patients achieving appropriate therapeutic trough levels of 15-20 mg/l. The trough concentration time measurement before the fourth dose was only carried out in 28 (41.8%) of the 67 patients.

Conclusion:

This study reveals a gap between the appropriate utilization of vancomycin with respect to the international guidelines in the studied Lebanese hospitals. It highlights the need for dosing and monitoring protocols suitable for vancomycin utilization in these hospitals.

An Observational Analysis of Medication Use During 5,727 Medical Emergency Team Activations at a Tertiary Referral Hospital

BACKGROUND

Medical emergency teams (METs) rescue deteriorating patients as the response arm of hospital rapid response systems. This study aimed to (1) investigate medication use during MET activations by describing the type, frequency and access sources of medications; and (2) assess associations between patient characteristics, MET activation criteria, and outcomes and MET medication use.

METHODS

A single-center, retrospective study from a prospective database of MET activations in an Australian tertiary referral hospital was undertaken. Consecutive adult MET activations over a 12-month period were included.

RESULTS

Across the study period, there were 5,727 MET activations with medications used at 33.5% (n = 1,920). Of 2,648 medications used, cardiac system agents (n = 944; 35.6%) were the most common category used, while intravenous electrolytes (n = 341; 12.9%) and opioid analgesics (n = 248; 9.4%).were the most frequently used medications. Most commonly, medications were sourced from ward stocks. High blood pressure, heart or respiratory rate, pain, and multiple activation criteria were associated with MET medication use (p < 0.001). Patients who required medications were less likely to remain on the ward, and immediate admission to the ICU was approximately doubled (odds ratio = 1.90; 95% confidence interval = 1.47-2.45).

CONCLUSION

Medication use by the MET was common and associated with escalation to intensive care. A wide variety of medications, principally from ward stocks, were used with some predictability based on activation criteria. Local system improvements have demonstrated that by focusing on common MET syndromes and medications, further investigation can refine and improve medication use and management systems for deteriorating patients.

Factors Associated with the Initiation of Long-Acting Injectable Paliperidone Palmitate Versus Aripiprazole Among Medicaid Patients with Schizophrenia: An Observational Study

INTRODUCTION

Factors underlying the selection of antipsychotics for patients with schizophrenia are poorly understood. This study investigated variables associated with initiation of treatment with the long-acting injectables paliperidone palmitate (LAI-PP) and aripiprazole LAI (LAI-AP) in Medicaid patients with schizophrenia.

METHODS

Adults with at least one medical or pharmacy claim for LAI-PP or LAI-AP from 1 January 2013 to 31 December 2016 were selected from the IBM^® MarketScan^® Medicaid Database. The date of the first LAI-PP or LAI-AP claim was the index date. Patients who had at least two medical claims, on different days, for a schizophrenia diagnosis and at least 12 months of continuous health plan enrollment prior to index date were included in the analysis. Multivariable logistic regression was performed to determine the factors associated with the initiation of LAI-PP versus LAI-AP.

RESULTS

Of included patients, 5501 initiated LAI-PP and 1449 initiated LAI-AP. Patients more likely to initiate LAI-PP versus LAI-AP were older, male, or African American (all p < 0.01). Patients with obesity (odds ratio [OR] 0.84; 95% confidence interval [CI] 0.71, 0.98), post-traumatic stress disorder (OR 0.76; 95% CI 0.63, 0.92), or prior oral antipsychotic use (OR 0.66; 95% CI 0.55, 0.79) were less likely to initiate LAI-PP; whereas, patients with nonorganic psychoses (OR 1.35; 95% CI 1.18, 1.55) or prior use of other injectable antipsychotics (OR 1.26; 95% CI 1.09, 1.47) were more likely to initiate LAI-PP versus LAI-AP. Patients with at least two all-cause hospitalizations were 1.37 times more likely to initiate LAI-PP vs LAI-AP (OR 1.37; 95% CI 1.18, 1.60).

CONCLUSION

Factors associated with initiating LAI-PP and LAI-AP differed. Notably, patients who initiated LAI-PP had greater prior use of medical services than LAI-AP patients. Understanding prescribing practices may help optimize treatment strategies and improve disease management.

FUNDING

Janssen Scientific Affairs, LLC.

Real-World Treatment Patterns Among Patients Initiating Small Molecule Kinase Inhibitor Therapies for Thyroid Cancer in the United States

Introduction

Little is known about real-world use of small molecule kinase inhibitors (SMKI) for advanced thyroid cancer in the United States. This study examined prescribing patterns of SMKI agents recommended by the National Comprehensive Cancer Center (NCCN).

Methods

This retrospective study used a national health insurance database to identify patients diagnosed with thyroid cancer during 1/1/2006–6/30/2016 and with prescription claims for NCCN-recommended SMKI during 1/1/2010–5/31/2016 whose first claim date was the index date. Inclusion also required continuous enrollment in a health plan for 3 months pre-index (baseline) and ≥ 1 month post-index (follow-up) with no claims for SMKI during baseline. Lines of therapy (LOT) were defined by the date of SMKI claims and days of drug supply. Median time to SMKI discontinuation in each LOT was estimated by Kaplan–Meier method.

Results

The study included 217 patients. During follow-up (mean duration 499.0 days), 35.5% of patients (n = 77) received a second or later LOT; among patients with ≥ 12 months follow-up after first LOT (LOT1) initiation, 53.1% (n = 60) received a second or later LOT. Median treatment duration was 5.0 months for LOT1 and 5.1 months for LOT2. Over the entire follow-up period (2010–2016), sorafenib was the most common regimen in LOT1 (36.9% of patients) and LOT2 (24.7%) followed by sunitinib and levantinib (13.4% each) in LOT1 and sunitinib (19.5%) in LOT2. Starting in 2015, the year lenvatinib was approved for differentiated thyroid cancer, lenvatinib was the most common first-line regimen among patients initiating LOT1 in 2015 (43.4%) and 2016 (66.7%).

Conclusion

Sorafenib was the most common first-line agent during 2010–2014 but was supplanted by lenvatinib starting in 2015. Approximately 36–53% of patients received a second-line treatment. Median treatment duration results suggested potential benefit of SMKI in second-line therapy. SMKI treatment after first-line failure may be considered for appropriately selected patients.

Funding

Eisai, Inc. (Woodcliff Lake, NJ).

Payments from drug companies to physicians are associated with higher volume and more expensive opioid analgesic prescribing

BACKGROUND

While the rise in opioid analgesic prescribing and overdose deaths was multifactorial, financial relationships between opioid drug manufacturers and physicians may be one important factor.

METHODS

Using national data from 2013 to 2015, we conducted a retrospective cohort study linking the Open Payments database and Medicare Part D drug utilization data. We created two cohorts of physicians, those receiving opioid-related payments in 2014 and 2015, but not in 2013, and those receiving opioid-related payments in 2015 but not in 2013 and 2014. Our main outcome measures were expenditures on filled prescriptions, daily doses filled, and expenditures per daily dose. For each cohort, we created a comparison group that did not receive an opioid-related payment in any year and was matched on state, specialty, and baseline opioid expenditures. We used a difference-in-differences analysis with linear generalized estimating equations regression models.

RESULTS

We identified 6,322 physicians who received opioid-related payments in 2014 and 2015, but not in 2013; they received a mean total of $251. Relative to comparison group physicians, they had a significantly larger increase in mean opioid expenditures ($6,171; 95% CI: 4,997 to 7,346), daily doses dispensed (1,574; 95%CI: 1,330 to 1,818) and mean expenditures per daily dose ($0.38; 95% CI: 0.29 to 0.47). We identified 8,669 physicians who received opioid-related payments in 2015, but not in 2013 or 2014; they received a mean total of $40. Relative to comparison physicians, they also had a larger increase in mean opioid expenditures ($1,031; 95% CI: 603 to 1,460), daily doses dispensed (557; 95% CI: 417 to 697), and expenditures per daily dose ($0.06; 95% CI: 0.002 to 0.13).

CONCLUSIONS

Our findings add to the growing public policy concern that payments from opioid drug manufacturers can influence physician prescribing. Interventions are needed to reduce such promotional activities or to mitigate their influence.

Getting What We Pay For: How Do Risk-Based Payments to Medicare Advantage Plans Compare with Alternative Measures of Beneficiary Health Risk?

OBJECTIVE

To estimate the relative health risk of Medicare Advantage (MA) beneficiaries compared to those in Traditional Medicare (TM).

DATA SOURCES/STUDY SETTING

Medicare claims and enrollment records for the sample of beneficiaries enrolled in Part D between 2008 and 2015.

STUDY DESIGN

We assigned therapeutic classes to Medicare beneficiaries based on their prescription drug utilization. We then regressed nondrug health spending for TM beneficiaries in 2015 on demographic and therapeutic class identifiers for 2014 and used coefficients from this regression to predict relative risk of both MA and TM beneficiaries.

PRINCIPAL FINDINGS

Based on prescription drug utilization data, beneficiaries enrolled in MA in 2015 had 6.9 percent lower health risk than beneficiaries in TM, but differences based on coded diagnoses suggested MA beneficiaries were 6.2 percent higher risk. The relative health risk based on drug usage of MA beneficiaries compared to those in TM increased by 3.4 p.p. from 2008 to 2015, while the relative risk using diagnoses increased 9.8 p.p.

CONCLUSIONS

Our results add to a growing body of evidence suggesting MA receives favorable, or, at worst, neutral selection. If MA beneficiaries are no healthier and no sicker than similar beneficiaries in TM, then payments to MA plans exceed what is warranted based on their health status.

Reducing potentially inappropriate drug prescribing in nursing home residents: effectiveness of a geriatric intervention

AIMS

Potentially inappropriate drug prescribing (PIDP) is frequent in nursing home (NH) residents. We aimed to investigate whether a geriatric intervention on quality of care reduced PIDP.

METHODS

We performed an ancillary study within a multicentric individually-tailored controlled trial (IQUARE trial). All NH received a baseline and 18-month audit regarding drug prescriptions and other quality of care indicators. After the initial audit, NHs of the intervention group benefited of an in-site intervention (geriatric education for NH staff) provided by a geriatrician from the closest hospital. The analysis included 629 residents of 159 NHs. The main outcome was PIDP, defined as the presence of at least one of the following criteria: (i) drug with an unfavourable benefit-to-risk ratio; (ii) with questionable efficacy; (iii) absolute contraindication; (iv) significant drug-drug interaction. Multivariable multilevel logistic regression models were performed including residents and NH factors as confounders.

RESULTS

PIDP was 65.2% (-3.6% from baseline) in the intervention group (n = 339) and 69.9% (-2.3%) in the control group (n = 290). The intervention significantly decreased PIDP [odds ratio (OR) = 0.63; 95% confidence interval 0.40-0.99], as a special care unit in NH (OR = 0.60; (0.42 to 0.85)), and a fall in the last 12 months (OR = 0.63; 0.44-0.90). Charlson Comorbidity Index [ORCCI = 1 vs. 0  = 1.38; 0.87-2.19, ORCCI ≥ 2 vs. 0  = 2.01; (1.31-3.08)] and psychiatric advice and/or hospitalization in a psychiatric unit (OR = 1.53; 1.07-2.18) increased the likelihood of PIDP.

CONCLUSION

This intervention based on a global geriatric education resulted in a significant reduction of PIDP at patient level.

Impact of medication reviews on inappropriate prescribing in aged care

BACKGROUND

Inappropriate prescribing (IP) is prevalent among elderly people in aged care facilities. Little has been published on the effect of pharmacists performing residential medication management reviews (RMMRs) in aged care on the appropriateness of prescribing. RMMRs represents a key strategy for achieving quality use of medicines, by assisting residents in aged care facilities and their carers to better manage their medicines. However, the structure of RMMR has moved from annual to every two years for each resident.

OBJECTIVES

The primary objective of this study was to investigate the impact of pharmacists performing RMMRs on medication use appropriateness, as measured by the Medication Appropriateness Index (MAI).

METHODS

Retrospective analysis of RMMRs pertaining to 223 aged care residents aged ≥65 years in Sydney, Australia. The MAI was applied on two RMMR cohorts; newer cohort (n = 111, 2015) i.e. following the recent changes to the RMMR funding and older cohort (n = 112, 2012) at baseline, after pharmacists' recommendations (assuming all pharmacists' recommendations were accepted by the General Practitioner [GP]), and after the actual uptake of pharmacists' recommendations by the GP. Differences in inappropriate prescribing were measured using the Wilcoxon sign rank test.

RESULTS

Overall, all patients in the study (n = 223) had at least one inappropriate rating at baseline (median MAI score of 26 for the old cohort and 27 for the newer cohort). The median cumulative MAI scores were significantly lower after the RMMRs by pharmacists (15.5 and 20 for the old and new cohort respectively, p < .001) and following the uptake of recommendations by the GP, indicating an increased appropriateness of drug regimen after the medication review (20 and 22 for the old and new cohort respectively, p < .001).

CONCLUSION

This study shows that pharmacist-led medication reviews are effective in reducing inappropriate prescribing among aged care residents, as demonstrated by the reduction in MAI scores. Future studies should focus on the impact of such a decrease on patient outcomes.

[Efficacy of Management for Rational Use of Antibiotics in Surgical Departments at a Multi-Disciplinary Hospital: Results of a 7-year Pharmacoepidemiological Research]

Background

Irrational medicine use including excessive use and abuse of antibiotics remains a crucial problem for the healthcare systems. In this regard, studies examining approaches to improving the clinical use of medicines are highly important.

Aim

to assess the efficacy rate of management for the rational use of antibiotics in surgical departments of a multi-disciplinary hospital.

Material and Methods

The intervention complex combined the research, educational, and methodological activities: local protocols for perioperative antibiotic prophylaxis (PABP) for various surgical departments were developed; local PABP protocols were discussed with the physicians of specialized surgical departments; official order on implementation of PABP was issued; the list of drug prescriptions for registration of the first pre-operative antibiotic dose was changed; audit and feedback processes were introduced as well as consultations of a clinical pharmacologist were implemented. We assessed the efficacy rate of the interventions basing on the changes in consumption of antibiotics (both quantitatively and qualitatively) at surgical departments of a hospital using ATC/DDD methodology. Comparison of the studied outcomes was performed before and after the intervention implementation and between the departments (vascular and abdominal surgery). The consumption of antibacterial agents (ATCJ01) was measured as a number of defined daily doses (DDD) per 100 bed-days (DDD/100 bed-days, indicator recommended by the World Health Organization, WHO) and DDD per 100 treated patients (DDD/100 treated patients).

Results

From 2006 to 2012, a decrease in antibacterial consumption in surgical departments by 188 DDD/100 treated patients was observed. We obtained the opposite results when using an indicator of DDD/100 bed-days (increase by 2.5 DDD/100 bed-days) which could be explained by the dependence on indices of overall hospital work and its changes during the examined period. Observed changes in antibacterial consumption varied in different surgical departments. The most pronounced positive changes were noted in the department of vascular surgery: decrease in total antibacterial consumption by 298 DDD/100 treated patients, decrease in the use of cephalosporins of the III generation from 141 to 38 DDD/100 treated patients. These positive changes were accompanied by the same (low) level of consumption/use of reserve antibiotics. In the department of abdominal surgery, there was no decrease in total antibiotic consumption, as well as in consumption of broad-spectrum cephalosporins of the III generation and fluoroquinolones, and we observed an increase in the use of reserve antibiotics (carbapenems) during the study period. Positive changes in antibiotic consumption were associated with the positive attitude of the manager/head of the department towards interventions: we observed the most pronounced decrease in antibiotic consumption straight after the publication of the administrative order on perioperative antibacterial prophylaxis.

Conclusion

The combination of scientific, educational, and methodological interventions is effective for improving antibiotic application. The study results provide the rationale for analyzing the drug consumption using the DDD/100 treated patients measure in addition to the WHO-recommended indicator of DDD/100 bed-days which depends on overall hospital performance.

Prospective evaluation of Ceftriaxone use in medical and emergency wards of Gondar university referral hospital, Ethiopia

Ceftriaxone is among the most commonly utilized antibiotics owing to its high potency, wide spectrum of activity, and low risk of toxicity. It is used to treat different types of bacterial infections including pneumonia, bone infections, abdominal infections, Skin and soft tissue infections, urinary tract infections. However, evidence around the globe shows the misuse of Ceftriaxone. This study aimed at evaluating the appropriateness of ceftriaxone use in medical and emergency wards of Gondar university referral hospital (GURH), Northwest Ethiopia. A prospective, cross-sectional study design was employed to evaluate the use of ceftriaxone. The medical records of patients who received ceftriaxone were reviewed prospectively between January 1 and March 30, 2017. Appropriateness of ceftriaxone use was evaluated as per the protocol developed from current treatment guidelines. A total of 390 patients' medical records were reviewed. The utilization rate of ceftriaxone was found to be high with a point prevalence of 59%. Ceftriaxone was empirically used in 79.5% of cases. The most common indications of Ceftriaxone were respiratory tract infections (29.3%), central nervous system infections (24.1%), and prophylactic indications (16.4%). The mean duration of ceftriaxone therapy in our study was 11.47 days, with a range of 1-52 days. More than two-thirds (80.2%) of ceftriaxone use were found to be inappropriate and majority of unjustified ceftriaxone use emanated from inappropriate frequency of administration (78.3%), absence of culture and sensitivity test (68.7%), and duration of therapy (47%). Empiric treatment with ceftriaxone and the presence of coadministered drugs was significantly associated with its inappropriate use. The present study revealed a very high rate of inappropriate use of ceftriaxone which may potentially lead to emergence of drug-resistant microorganisms and ultimately exposes the patient to treatment failure and increased cost of therapy.

Constraints on Formulary Design Under the Affordable Care Act

I study the effect of prescription drug essential health benefits (EHB) requirements from the Affordable Care Act on prescription drug formularies of health insurance marketplace plans. The EHB regulates the number of drugs covered but leaves other dimensions (cost sharing and utilization management) of the formulary unregulated. Using data on almost all formularies in the country, I demonstrate that requiring insurers to cover one additional drug adds 0.22 drugs (3.3%) to the average formulary, mostly owing to firms increasing the number of drugs covered to comply with the EHB requirement. The EHB requirement also increases the probability that a drug is subject to utilization management and is assigned to a higher (more costly) formulary tier. My results suggest that newly covered drugs are 22.3 percentage points more likely to be subject to utilization management, compared to 36.7% for the average covered drug. Using formularies for Medicare Advantage plans, which are subject to uniform, nationwide benefit design standards, and the formulary status of newly approved drugs that do not satisfy the EHB requirement, I reject the hypotheses that consumer demand or effects on plan entry can explain my results. Copyright © 2017 John Wiley & Sons, Ltd.

Contemporary Trends and Outcomes Associated With the Preprocedural Use of Oral P2Y12 Inhibitors in Patients Undergoing Percutaneous Coronary Intervention: Insights From the Blue Cross Blue Shield of Michigan Cardiovascular Consortium (BMC2)

OBJECTIVES

We sought to describe trends in the use of preprocedural P2Y12 inhibitors and their clinical impact in patients undergoing percutaneous coronary intervention (PCI).

BACKGROUND

Oral P2Y12 inhibitors are ubiquitously used medications; however, the specific timing of initial P2Y12 inhibitor administration remains intensely debated.

METHODS

Our study population comprised 74,053 consecutive patients undergoing PCI at 47 hospitals in Michigan from January 2013 through June 2015. In-hospital outcomes included stent thrombosis, bleeding, need for transfusion, and death. Hierarchical logistic regression, propensity matching, and targeted maximum likelihood estimation were used to adjust for baseline patient differences and clustering, and to minimize bias.

RESULTS

Of 24,733 patients who received a preprocedural P2Y12 inhibitor, 82% received clopidogrel, 8% prasugrel, and 10% ticagrelor. Preprocedural administration of P2Y12 inhibitors declined during the study (49.3% to 24.8%; P<.001), and varied greatly across hospitals (14.5%-95.9%). No significant differences in outcomes were observed between patients receiving preprocedural clopidogrel and a matched cohort of those not receiving any preprocedural P2Y12 inhibitor (stent thrombosis: adjusted odds ratio [OR], 1.55; 95% confidence interval [CI], 0.30-7.84; bleeding: OR, 0.96; 95% CI, 0.63-1.46; transfusion: OR, 1.03; 95% CI, 0.69-1.55; and death: OR, 0.95; 95% CI, 0.38-2.37). Similar findings were demonstrated for preprocedural ticagrelor and prasugrel. Results from a subgroup analysis of patients with non-ST segment elevation acute coronary syndrome (n = 28,072) were consistent with the overall findings.

CONCLUSIONS

There was a substantial decline in the rate of preprocedural P2Y12 inhibitor administration during the study. Furthermore, there were no significant differences in outcomes between patients treated with preprocedural P2Y12 inhibitors and those who were not.

Montelukast use-a 19-year nationwide drug utilisation study

PURPOSE

Montelukast is a leukotriene receptor antagonist used in asthma and rhinitis treatment. Despite being marketed nearly two decades ago, little is known about its utilisation pattern.

METHODS

Using the Danish National Prescription Registry, we identified subjects filling a montelukast prescription between 1998 and 2017. Using descriptive statistics, we reported the development in incidence, and prevalence, as well as a measure of treatment duration, and concomitant use of asthma- or anti-allergic therapy.

RESULTS

We identified 147,247 individuals filling 1,327,489 montelukast prescriptions. A total of 54,349 users (37%) filled only one montelukast prescription. The prevalence increased from 0.9/1000 persons in 1998 to 3.3/1000 persons in 2016. The rate of new users reached its maximum of 2.1/1000 person-years in 2009. Among new montelukast users, 28% were still users after 1 year. Among all montelukast initiators, 60% filled at least one prescription of short-acting beta-2-agonists (SABA) up to a year prior to montelukast initiation, and 49% filled a prescription of inhaled corticosteroids (ICS). Only 0.8% (n = 1148) of all individuals initiated montelukast without a redeemed prescription of short- or long-term inhalation therapy, systemic antihistamines, or nasal topical anti-allergic treatment.

CONCLUSIONS

The usage of montelukast has increased over threefold since its market entry in 1998, mainly driven by an increased number of prevalent users. The majority of individuals who initiated montelukast filled a prescription of SABA up to a year prior to montelukast initiation, whereas almost half filled a prescription of ICS.

Factors Associated with Opioid Dose Increases: A Chart Review of Patients' First Year on Long-Term Opioids

Objective

To examine encounter-level factors associated with opioid dose increases during patients' first year on opioid therapy for chronic pain.

Design

Case-control study analyzing all opioid prescriptions for patients with chronic pain during their first year after opioid initiation. Cases were patients who experienced an overall dose escalation of ≥ 30 mg morphine equivalents over the 1-year period; controls did not experience overall dose escalation. Main measures were encounter type, opioid dose change, documented prescribing rationale, documentation of guideline-concordant opioid-prescribing practices. Two coders reviewed all encounters associated with opioid prescriptions. Analysis of factors associated with dose increases and provider documentation of prescribing rationale was conducted using multiple logistic regression.

Results

There were 674 encounters coded for 66 patients (22 cases, 44 controls). Fifty-three percent of opioid prescriptions were associated with telephone encounters; 13% were associated with e-mail encounters. No prescribing rationale was documented for 43% of all opioid prescriptions and 25% of dose increases. Likelihood of dose increase and documentation of prescribing rationale did not significantly differ for cases versus controls. Compared with face-to-face encounters, dose increases were significantly less likely for telephone (OR 0.18, 95% CI 0.11-0.28) and e-mail (OR 0.23, 95% CI 0.12-0.47) encounters; documentation of prescribing rationale was significantly more likely for e-mail (OR 5.06, 95% CI 1.87-13.72) and less likely for telephone (OR 0.30, 95% CI 0.18-0.51) encounters.

Conclusion

Most opioid prescriptions were written without face-to-face encounters. One quarter of dose increases contained no documented prescribing rationale. Documented encounter-level factors were not significantly associated with overall opioid dose escalation.

Survey of topical oral solutions for the treatment of chemo-induced oral mucositis

Purpose. The objectives of this study were (1) to describe the usage of topical oral solutions in patients experiencing chemotherapy-induced oral mucositis (CIOM); and (2) to survey the care of oral mucositis provided to patients by clinical oncology pharmacists in institutional settings.

Methods. Surveys were distributed to institutional pharmacists in the US, who were asked to provide the components of their ‘magic mouthwash’. Other questions included whether an institutional mucositis management guideline is available and what is the involvement of clinical pharmacy in mucositis care.

Results. Forty institutions returned surveys during the study period. The top five ingredients used to compound the magic mouthwash are diphenhydramine, viscous lidocaine, magnesium hydroxide/aluminum hydroxide, nystatin and corticosteroids. Most institutions administer the mouthwash every 4 hours (36%) or every 6 hours (36%). Of the surveyed institutions, 33% currently possess guidelines for the management of CIOM.

Conclusions. Most institutions in the country formulate their topical solution, or magic mouthwash, with a variety of ingredients. There is a need to standardize the ingredients used to compound the magic mouthwash, in order to fully evaluate the efficacy of the solution to manage CIOM.

Assessment of ovarian failure and osteoporosis in premenopausal breast cancer survivors

Premenopausal women who develop ovarian failure after receiving chemotherapy are at a higher risk of rapid bone loss. Pharmacists have successfully implemented osteoporosis screening programmes in the general population and thus, assessment of breast cancer survivors for ovarian failure and osteopenia could represent a novel focus for oncology pharmacists. Therefore, we conducted a retrospective chart review to determine the adequacy of ovarian failure and osteoporosis assessment and management in premenopausal breast cancer survivors.

Methods and results. The charts of 20 women diagnosed with early stage breast cancer treated with cyclophosphamide over a 4.5-year timespan were included. Their median age was 36.7 years (range 29.8-41). The median cyclophosphamide cumulative dose was 9 g/m2 (range 2.4-14.45), with a median duration of follow-up being 4.62 years. The assessment of ovarian failure mainly occurred by documenting menstrual periods, which has been questioned as a reliable method for assessing ovarian failure. Menses stopped while or shortly after receiving chemotherapy in 11 women. Prior to and during cyclophosphamide administration, osteoporosis screening or counselling was not documented for any patient. After completion of chemotherapy administration, eight patients were counselled regarding osteoporosis and seven women were screened for osteoporosis with a dual X-ray absorptimetry (DXA) scan. Five women had DXA scans indicative of osteopenia according to World Health Organization guidelines.

Conclusions. Improvements are needed in the documentation and potentially also the management of ovarian failure and osteoporosis in premenopausal breast cancer survivors receiving cyclophosphamide-based regimens. This represents a potential opportunity for pharmacists to manage long-term chemotherapy toxicity.

Contrast Utilization During Chronic Total Occlusion Percutaneous Coronary Intervention: Insights From a Contemporary Multicenter Registry

BACKGROUND

Administration of a large amount of contrast volume during chronic total occlusion (CTO) percutaneous coronary intervention (PCI) may lead to contrast-induced nephropathy.

METHODS

We examined the association of clinical, angiographic and procedural variables with contrast volume administered during 1330 CTO-PCI procedures performed at 12 experienced United States centers.

RESULTS

Technical and procedural success was 90% and 88%, respectively, and mean contrast volume was 289 ± 138 mL. Approximately 33% of patients received >320 mL of contrast (high contrast utilization group). On univariable analysis, male gender (P=.01), smoking (P=.01), prior coronary artery bypass graft surgery (P=.04), moderate or severe calcification (P=.01), moderate or severe tortuosity (P=.04), proximal cap ambiguity (P=.01), distal cap at a bifurcation (P<.001), side branch at the proximal cap (P<.001), blunt/no stump (P=.01), occlusion length (P<.001), higher J-CTO score (P=.02), use of antegrade dissection and reentry or retrograde approach (P<.001), ad hoc CTO-PCI (P=.04), dual arterial access (P<.001), and 8 Fr guide catheters (P<.001) were associated with higher contrast volume; conversely, diabetes mellitus (P=.01) and in-stent restenosis (P=.01) were associated with lower contrast volume. On multivariable analysis, moderate/severe calcification (P=.04), distal cap at a bifurcation (P<.001), ad hoc CTO-PCI (P<.001), dual arterial access (P=.01), 8 Fr guide catheters (P=.02), and use of antegrade dissection/reentry or the retrograde approach (P<.001) were independently associated with higher contrast use, whereas diabetes (P=.02), larger target vessel diameter (P=.03), and presence of "interventional" collaterals (P<.001) were associated with lower contrast utilization.

CONCLUSIONS

Several baseline clinical, angiographic, and procedural characteristics are associated with higher contrast volume administration during CTO-PCI.

Prevalence of Nosocomial Infection and Antibiotic Use at a University Medical Center in Malaysia

Background and Objective:

Most reports of nosocomial infection (NI) prevalence have come from developed countries with established infection control programs. In developing countries, infection control is often not as well established due to lack of staff and resources. We exMnined the rate of N1 in our institution.

Methods:

A point-prevalence study of N1 and antibiotic prescribing was conducted. On July 16 and 17, 2001, all inpatients were surveyed for N1, risk factors, pathogens isolated, and antibiotics prescribed and their indication. NIs were diagnosed according to CDC criteria. Cost of antibiotic acquisition was calculated by treatment indication.

Setting:

Tertiary-care referral center in Malaysia.

Patients:

All inpatients during the time of the study.

Results:

Five hundred thirty-eight patients were surveyed. Seventy-five had 103 NIs for a prevalence of 13.9%. The most common NIs were urinary tract infections (12.29-6), pneumonia (21.4%), laboratory-confirmed bloodstream infections (12.2%), deep surgical wound infections (11.2%), and clinical sepsis (22.4%).Pseudomonas aeruginosa, MRSA, and MSSA were the most common pathogens. Two hundred thirty-seven patients were taking 347 courses of antibiotics, for an overall prevalence of antibiotic use of 44%. N1 treatment accounted for 36% of antibiotic courses prescribed but 47% of antibiotic cost. Cost of antibiotic acquisition for N1 treatment was estimated to be approximately 2 million per year (Malaysian dollars).

Conclusion:

Whereas the rate of N1 is relatively high at our center compared with rates from previous reports, antibiotic use is among the highest reported in any study of this kind. Further research into this high rate of antibiotic use is urgently required.

[Medication review in the mental health care service: experiences on long-stay units]

BACKGROUND

Medication review is a recurrent, structured and critical evaluation of pharmacotherapy by patient, physician and pharmacist. The Dutch Health Care Inspectorate considers medication review to be a way of improving the quality and safety of drug treatment. However, little is known about the costs, effectiveness and feasibility of medication review in the practice of mental health care.

AIM

To obtain an impression of the costs and benefits of a first medication review in a clinical mental health care setting with chronic patients.

METHOD

In 2013, the mental health organisation Yulius enrolled 70 hospitalised chronic patients for a first medication review. A detailed record was kept of the prescribed medication, medication changes, and the time invested.

RESULTS

More than half of the proposed changes in medication were eventually implemented; 20% of these changes were made during a planned evaluation after three months. The number of drugs prescribed decreased after medication review; the reduction applied more often to somatic medication than to psychotropic medication. Costs relating to medication reviews seemed to be at least in balance with the benefits.

CONCLUSION

In the group of patients with severe mental disorder, medication review seems to provide a good opportunity to assess the rationality of pharmacotherapy in a multidisciplinary approach. The time invested appears to be offset by the benefits of medication review.

The effect of the introduction of a nationwide DUR system where local DUR systems are operating--The Korean experience

OBJECTIVE

Outpatient clinics in Korea usually have local DUR (drug utilisation review) systems, which are integrated with EMRs or health insurance claims submission systems. Whenever, the government announces a list of drug contraindications, each local DUR system loads the list and applies it in practice. In December 2010, a nationwide DUR system was introduced. This study is to investigate the impact of the nationwide DUR system on prescribing practices where local DUR systems are already operating.

METHODS

Between January 2009 and December 2012 the monthly number of drugs per prescription was retrieved from the health insurance claims data warehouse at the Health Insurance Review and Assessment (HIRA). The monthly proportions of 3 DDI (drug-drug interaction) pairs, 6 drug-age contraindications, and 3 drug-pregnancy contraindications from January 2007 to December 2012, at the outpatient clinic level, were also retrieved. An interrupted time series analysis was used for controlling government announcements of drug contraindications.

RESULTS

There was no difference in the number of drugs per prescription before and after the introduction of the nationwide DUR system. Most proportions of the 3 DDI pairs, 6 drug-age contraindications, and 3 drug-pregnancy contraindications, were significantly reduced following the government announcement of drug contraindications in the short term and/or long term.

CONCLUSION

The number of drugs per prescription was not related to the nationwide DUR introduction in places where local DUR systems are operating. The introduction of duplicate guidelines, in locations where the guidelines were already well followed, is considered to be the main reason for this. Furthermore, the Doctor's ignorance of alerts, and their continued substitution of regulated drugs, for non-regulated drugs, likely played a role in nullifying the effectiveness of the nationwide DUR system.

Nine-year trends in the morbidity of mental disorders and psychotropic drug utilization in Croatia: over-diagnosis and over-utilization?

Overall drug overuse, including psychotropic, is the Croatian reality. Therefore, in between 2000 and 2012, the interventions to control drug overspending were undertaken. The main aims of the study are: to determine the morbidity trends of mental disorders registered in family medicine (FM), the trends in psychotropic drug utilization and to identify whether the trends of utilization have any relation to the interventions. The results indicate that mental disorders represent a high disease burden in Croatia. It was also present a higher burden of psychotropic drug utilization; second ranked in the total drug utilization during the nine-year follow up period. The utilization of psycholeptic's, was even higher; from 2004 to 2008; those drugs were ranked first in terms of utilization. Between 20-25% of Croatia's total health care budget is usually spent on drugs. The interventions that are currently being implemented to control drug utilization have not brought about any changes.

Does antidepressant medication use affect persistence with diabetes medicines?

PURPOSE

This study aimed to examine the effect of antidepressant use on persistence with newly initiated oral antidiabetic medicines in older people.

METHODS

A retrospective study of administrative claims data from the Australian Government Department of Veterans' Affairs, from 1 July 2000 to 30 June 2008 of new users of oral antidiabetic medicines (metformin or sulfonylurea). Antidepressant medicine use was determined in the 6 months preceding the index date of the first dispensing of an oral antidiabetic medicine. The outcome was time to discontinuation of diabetes therapy in those with antidepressant use compared with those without. Competing risks regression analyses were conducted with adjustment for covariates.

RESULTS

A total of 29,710 new users of metformin or sulfonylurea were identified, with 7171 (24.2%) dispensed an antidepressant. Median duration of oral antidiabetic medicines was 1.81 years (95% CI 1.72–1.94) for those who received an antidepressant at the time of diabetes medicine initiation, by comparison to 3.23 years (95% CI 3.10–3.40) for those who did not receive an antidepressant. Competing risk analyses showed a 42% increased likelihood of discontinuation of diabetes medications in persons who received an antidepressant (subdistribution hazard ratio 1.42, 95% CI 1.37–1.47, p < 0.001).

CONCLUSIONS

The results of this large population-based study demonstrate that depression may be contributing to non-compliance with medicines for diabetes and highlight the need to provide additional services to support appropriate medicine use in those initiating diabetes medicines with co-morbid depression.

Using a morphine equivalence metric to quantify opioid consumption: examining the capacity to provide effective treatment of debilitating pain at the global, regional, and country levels

CONTEXT

Morphine has been considered the gold standard for treating moderate-to-severe pain, although many new opioid products and formulations have been marketed in the last two decades and should be considered when examining opioid consumption. Understanding opioid consumption is improved by using an equianalgesic measure that controls for the strengths of all examined opioids.

OBJECTIVES

The research objective was to use a morphine equivalence (ME) metric to determine the extent that morphine consumption relates to the total consumption of all other study opioids.

METHODS

An ME metric was created for morphine and the aggregate consumption of each study opioid (Total ME), adjusted for country population to allow for uniform equianalgesic comparisons. Graphical and statistical evaluations of morphine use and Total ME consumption trends (between 1980 and 2009) were made for the global and geographic regional levels and selected developed and developing countries.

RESULTS

Global morphine consumption rose dramatically in the early 1980s but has been significantly outpaced by Total ME since 1996. As expected, the extent of morphine and Total ME consumption varied notably among regions, with the Americas, Europe, and Oceania regions accounting for the highest morphine use and Total ME in 2009. Developing and least developed countries, compared with developed countries, demonstrated lower overall Total ME consumption.

CONCLUSION

Generally, worldwide morphine use has not increased at the rate of Total ME, especially in recent years. Examining a country's ability to effectively manage moderate-to-severe pain should extend beyond morphine to account for all available potent opioids.

Patterns of Drug Utilization in a Neonatal Intensive Care Unit

The objective of this study was to determine drug use in newborns at an inborn tertiary care neonatal intensive care unit, serving a predominantly African American population, to identify educational/research priorities in neonatal drug therapy. Data on demographics and exposure rates to all drugs from 6839 neonates born between January 1997 and June 2004 were analyzed. Number of drugs used was correlated with race, gender, gestational age, birthweight, and survival status. The contribution of these factors to mean drug use was predicted by multivariate regression analysis. In this population of 80% African Americans, mean drug use was 3.6/infant, with the highest use in the 24- to 27-week gestational age group (11.7/infant). Ampicillin and cefotaxime had the highest exposure rates. Premature infants had high use of surfactant, pressor agents, and diuretics. Caucasians, males, gestational age<28 weeks, and birthweight<1000 g were the risk factors for higher drug exposure. Future research/education must emphasize these therapeutic areas with priority assigned to low-birthweight infants.

Improving the success of mailed letter intervention programs to influence prescribing behaviors: a review

BACKGROUND

Educational interventions have long been used as a means of influencing prescribing behavior. Various techniques including educational mailings, academic detailing, prescriber feedback with or without disclosing patient-identifying data, and supplemental patient information have been used to promote appropriate prescribing habits, reduce costs, and optimize patient care. While the effects of educational intervention programs are widely reported, little information is available regarding the effectiveness of various mailed intervention techniques.

OBJECTIVE

To review the effectiveness of mailed intervention programs and identify factors that may promote successful outcomes.

METHODS

A literature search was conducted via PubMed for reports of mailed intervention programs published through May 2012. Specific search terms included "drug utilization review," "drug utilization," "Medicaid," "prescribing feedback," "mailed physician intervention," and "mailed physician communications." Identified publications that met the following criteria were selected for inclusion: (a) evaluated printed educational materials disseminated via postal mail, (b) occurred in an outpatient setting, and (c) measured intervention impact on prescribing patterns, health care utilization, or economic outcomes. Publications that met all 3 criteria were abstracted for intervention strategy, follow-up period, data source, intervention target, prescriber acceptance of intervention, and effect on prescribing patterns, health care utilization, and economic outcomes.

RESULTS

A total of 40 published reports regarding 39 unique interventions met inclusion criteria. The majority (34/39 [87.2%]) of studies were conducted in state or federally funded programs; only 5 programs involved private insurers. All programs used follow-up periods of ≤12 months after final intervention mailing. A total of 26 of the 39 unique interventions reported a positive impact on at least 1 target outcome. Programs that included a second recipient such as pharmacists (n = 4) reported a greater impact as compared with interventions mailed to prescribers alone. Programs that provided patient-identifying data had a higher success rate than those that supplied prescriber feedback and/or educational materials (21/25 [84.0%] vs. 5/14 [35.7%]); it should be noted that 2 of the 5 successful programs that provided nonpatient-identifying materials also used academic detailing. Programs that sent education material and/or prescriber feedback pertaining to multiple medication classes or disease states had minimal impact on prescribing patterns (n = 4). However, targeting 1 specific disease or medication supported by appropriate evidence resulted in favorable change in a short period of time. Additionally, providing recommendations that were supported by widely accepted clinical guidelines or literature were also associated with a high rate of success. A subset of programs that sought to evaluate health care utilization (n=5) and economic impact (n = 9) observed little change in measured outcomes. Evaluation of prescriber response forms conducted by 7 programs revealed that changes in therapy occurred in approximately 50% of patients with prescribers who intended to accept intervention recommendations.

CONCLUSIONS

Though the degree of heterogeneity between articles prevents provision of definite results, it appears that a well-constructed mailed intervention program has the potential to evoke significant changes in prescribing patterns. Prescribers appear to be receptive to mailed interventions; however, there are limited data to determine the association between acceptance and actual prescribing change. Future research should focus on identifying barriers that may prohibit acceptance of recommendations from translating into changes in therapy. Additionally, future projects should include longer assessment periods to determine the duration of impact following final intervention mailing and potential effect on health care and economic outcomes.

The effect of using the health smart card vs. CPOE reminder system on the prescribing practices of non-obstetric physicians during outpatient visits for pregnant women in Taiwan

INTRODUCTION

There is an evidence that pregnant women have been prescribed a significant number of improper medications that could lead to potential damage for a developing fetus due to discontinuity of care. The safety of pregnant women raises public concern and there is a need to identify ways to prevent potential adverse events to the pregnant woman. This study used a health smart card with a clinical reminder system to keep continuous records of general outpatient visits of pregnant women to protect them from potential adverse events caused by improper prescription.

METHOD

The health smart card, issued to all 23 million citizens in Taiwan, was used to work with a Computerized Physician Order Entry (CPOE) implemented at a 700-bed teaching medical center in Taipei to provide the outpatient information of pregnant women. FDA pregnancy risk classification was used to categorize the risk of pregnant women. The log file, combined with the physicians' and patients' profiles, were statistically examined using the Mantel-Haenszel technique to evaluate the impact of system in changing physician's prescription behavior.

RESULTS

A total of 441 patients ranged in age from 15 to 50 years with 1114 prescriptions involved in FDA pregnancy risk classification C, D, and X during the study period. 144 reminders (13.1%) were accepted by physicians for further assessment and 100 (69.4%) of them were modified. Non-obstetric physicians in non-emergency setting were more intended to accept reminders (27.8%, 4.9 folds than obstetricians). Reminders triggered on patients in second trimester (15.5%) were accepted by all physicians more than third trimester (OR 1.52, p<0.05).

CONCLUSION

A health smart card armed with CPOE reminder system and well-defined criteria had the potential to decrease harmful medication prescribed to pregnant patients. The results show better conformance for non-obstetric physicians (26%) and when physicians accepted the alerts they are more likely to went back and review their orders (69%). In sum, reminder criteria of FDA pregnancy risk classification C for obstetricians and reminder based on different trimesters is suggested to be refined to improve system acceptability and to decrease improper prescription.

Psychotropic drug use in a sample of general population in the Sardinia region

Summary

Aims - To present the results of an epidemiologic research about psychotropic drug use inSardinia. Methods - Cross-sectional study on a sample of 1040 subjects randomly selected from registers. Setting - Community survey on three areas of Sardinia region. Evaluation: interviews carried out byphysicians by means of Italian version of the Composite International Diagnostic Interview Simplified.Drug consumption was evaluated concerning last week before the interview. Main Outcome Measures: point prevalence. Results - The rate of adults of the general population that consumed benzodiazepines was 10.1%, antidepressants 4.2%, 14.7% of the sample was using psychotropic drugs. 60% of subjects with diagnosis of ICD-10 Depressive Episod did not have the right pharmacologic treatment. A relevant proportion of subjects without lifetime psychiatric diagnosis (anxiety and/or depression) used antidepressants (0.8%). The pharmacologic therapies were managed by psychiatrics in 44.2% of cases, antidepressants were managed by general practitioners in 31.8% of subjects. Conclusions - The research underlines an increase of meet needs in subjects affected by depressive episodes against a previous Sardinian survey carried out over ten years ago. This change is parallel to a more frequent management of therapies by general practitioners. Their role seems to become more relevant in treating depressive illness.

Declaration of Interest

Mauro Giovanni Carta has received grants and research support from Regione Autonoma della Sardegna, Council of the European Union, European Union DGXII, GlaxoSmithKline, Pfizer, Lundbeck, Pharmacia, Recordati. Maria Carolina Hardoy has received grants and research support from University of Pisa, GlaxoSmithKline, Pfizer, Farmades. Bernardo Carpiniello has received grants and research support from GlaxoSmithKline, Pfizer, Recordati, Janssen Cilag, EliLilly, Astra Zeneca.

Impact of thiazolidinedione safety warnings on medication use patterns and glycemic control among veterans with diabetes mellitus

AIMS

In 2007, safety warnings were publicized regarding the association between thiazolidinediones (TZDs) and cardiovascular risks. This study investigated the impact of the publicized safety warnings on glycemic outcomes in patients with diabetes mellitus (DM).

MATERIALS AND METHODS

The Veterans Integrated Services Network 16 database included 13,293 DM patients using TZDs (n=13,037 rosiglitazone, n=246 pioglitazone, n=10 both) during a baseline period of 03/01/07 to 05/31/07. Three medication use patterns groups (09/01/07 to 11/30/07) were defined as follows: (1) continuation on TZD treatment, (2) switching to other non-TZD treatment, (3) discontinuation of TZD treatment without any antidiabetic treatment. Primary outcome (09/01/07 to 02/29/08) was change from baseline in A1c. The analysis of variance was used to test the association between use patterns and A1c change. A logistic regression model was used to identify the predictors for use patterns.

RESULTS

Patients (45.1%, n=5999) discontinued their TZD use. Both Groups 2 and 3 had significant A1c increases (both P values <.0001). Significant predictors for TZD discontinuation included black race, baseline heart disease, and diabetic complication [odds ratio (OR), 1.43; OR, 1.54; OR, 1.30, respectively]. Of the patients remaining on TZD therapy, 11.8% experienced improved A1c levels, and a lower percentage of patients (9.53%) experienced a deterioration in A1c levels (P<.0001). Patients who switched or discontinued an antidiabetic medication experienced improvements in body mass index (P<.0001) and triglycerides (P<.0036). The three use pattern groups had similar changes with regard to blood pressure and low-density lipoprotein.

CONCLUSION

Thiazolidinedione safety warnings may have negatively impacted the glycemic control in DM patients.

Utilization of anti-Parkinson drugs in Australia: 1995-2009

PURPOSE

To examine trends in the prescribing of anti-Parkinsonian drugs (APD) in Australia from 1995 to 2009.

METHODS

We analyzed the Medicare Australia and Drug Utilisation Sub-Committee (DUSC) databases for prescription data for overall APD dispensed use from 1995. We were able to examine prescribing by gender, age, and type of prescriber between 2002 and 2009. Prescriptions were converted to defined daily doses (DDD)/1000 population/day using Australian Bureau of Statistics population data.

RESULTS

Dispensed use of levodopa + carbidopa remained steady from 1995 to 2009 (0.76-0.82 DDD/1000 population/day); levodopa + benserazide use increased from 0.34 to 0.55 DDD/1000 population/day. Since 2005 dispensed use of levodopa + carbidopa + entacapone has steadily increased, from 0.03 to 0.10 DDD/1000 population/day. In July 2009 levodopa + carbidopa was the most widely used agent, followed by levodopa + benserazide, then benztropine. Cabergoline increased from 1999, peaked in 2006, and thereafter declined. APD use peaked in males and females aged 60-69 years. Age-adjusted utilization was slightly higher in males than females.

CONCLUSIONS

The amount of levodopa dispensed has slowly increased with levodopa + benserazide increasing faster than levodopa + carbidopa. Use of cabergoline fell when pramipexole became available and the risk of ergot-related serosal adverse effects was more widely appreciated. Use of centrally acting anti-cholinergics decreased over a period of time when use of atypical anti-psychotic agents increased.

Different patterns of inappropriate antimicrobial use in surgical and medical units at a tertiary care hospital in Switzerland: a prevalence survey

Background

Unnecessary or inappropriate use of antimicrobials is associated with the emergence of antimicrobial resistance, drug toxicity, increased morbidity and health care costs. Antimicrobial use has been reported to be incorrect or not indicated in 9–64% of inpatients. We studied the quality of antimicrobial therapy and prophylaxis in hospitalized patients at a tertiary care hospital to plan interventions to improve the quality of antimicrobial prescription.

Methodology/Principal Findings

Experienced infectious diseases (ID) fellows performed audits of antimicrobial use at regular intervals among all patients—with or without antimicrobials—hospitalized in predefined surgical, medical, haemato-oncological, or intensive care units. Data were collected from medical and nursing patient charts with a standardized questionnaire. Appropriateness of antimicrobial use was evaluated using a modified algorithm developed by Gyssens et al.; the assessment was double-checked by a senior ID specialist.

We evaluated 1577 patients of whom 700 (44.4%) had antimicrobials, receiving a total of 1270 prescriptions. 958 (75.4%) prescriptions were for therapy and 312 (24.6%) for prophylaxis. 37.0% of therapeutic and 16.6% of prophylactic prescriptions were found to be inappropriate. Most frequent characteristics of inappropriate treatments included: No indication (17.5%); incorrect choice of antimicrobials (7.6%); incorrect application of drugs (9.3%); and divergence from institutional guidelines (8%). Characteristics of inappropriate prophylaxes were: No indication (9%); incorrect choice of antimicrobials (1%); duration too long or other inappropriate use (6.7%). Patterns of inappropriate antimicrobial varied widely in the different hospital units; empirical prescriptions were more frequently incorrect than prescriptions based on available microbiological results.

Conclusions/Significance

Audits of individual patient care provide important data to identify local problems in antimicrobial prescription practice. In our study, antimicrobial prescriptions without indication, and divergence from institutional guidelines were frequent errors. Based on these results, we will tailor education, amend institutional guidelines and further develop the infectious diseases consultation service.

[European Antibiotic Awareness Day educational campaign--has it changed public attitudes to antibiotic use in Poland?]

Widespread inappropriate antibiotic use is a global concern for public health care. That is why national and international antibiotic resistance control strategies recommend education of health-care professionals and the public to promote prudent antibiotic use. This paper show the effect of the 2009 public antibiotic campaign in Poland on the knowledge and social attitudes towards use of antibiotics. The aim of this study was to assess the level of knowledge and behaviour models of Polish people regarding antibiotics, recommendations for their use as well as sources of information on antibiotics. At the same time the study was aimed at assessing whether actions undertaken during educational campaigns resulted in growing knowledge on the subject of antibiotic use or a change in attitudes towards this group of medicines.

MATERIAL AND METHODS

A two-stage survey was carried out from October to December 2009 based on 14 self prepared questions. The survey was carried out by Millward Brown SMG/KRC on the representative sample of 1000 people using CATI - Computer Assisted Telephone Interviews.

RESULTS

In Poland there is still a high percentage of people taking antibiotics. 37% of Polish people used an antibiotic in the last 12 months. Most Polish people--88% use an antibiotic prescribed by a doctor. At the same time Polish people receive antibiotics due to viral infections which should not be treated thus. The results of the survey show that almost half of adult Poles would expect to have an antibiotic prescribed in case of a flu. Over half of Polish people believe that antibiotics kill viruses. Over 1/3 of recipients, who have come across information on prudent use of antibiotics (mostly due to National Program for Antibiotics Protection) claimed to have changed their behavior model regarding this group of medicines.

CONCLUSIONS

The results of this study show that further and systematic education regarding appropriate antibiotic use is needed.

How was patient empowerment portrayed in information leaflets describing the community pharmacy Medicines Use Review service in the UK?

OBJECTIVE

The Medicines Use Review (MUR) community pharmacy service was introduced in 2005 to enhance patient empowerment but the service has not been taken up as widely as expected. We investigated the depiction of the patient-pharmacist power relationship within MUR patient information leaflets.

METHODS

We identified 11 MUR leaflets including the official Department of Health MUR booklet and through discourse analysis examined the way language and imagery had been used to symbolise and give meaning to the MUR service, especially the portrayal of the patient-pharmacist interactions and the implied power relations.

RESULTS

A variety of terminology was used to describe the MUR, a service that aimed ultimately to produce more informed patients through the information imparted by knowledgeable, skilled pharmacists.

CONCLUSION

The educational role of the MUR overshadowed the intended patient empowerment that would take place with a true concordance-centred approach. Although patient empowerment was implied, this was within the boundaries of the biomedical model with the pharmacist as the expert provider of medicines information.

PRACTICE IMPLICATIONS

If patient empowerment is to be conveyed this needs to be communicated to patients through consistent use of language and imagery that portrays the inclusivity intended.

[Impact of misuse of antimicrobial therapies on inpatient costs]

OBJECTIVE

To evaluate the impact of inappropriate antibiotic use on inpatients' cost during hospitalization.

METHODS

1 000 cases with antibiotic treatment were extracted from 10 hospitals of 5 provinces in China in 2005. We created multivariate linear regression model for hospital cost and Logistic regression model for evaluation of rationality in antibiotic use.

RESULTS

We collected 946 valid cases. Rate of inappropriate antibiotic use was 58.4%. Costs of inpatients with inappropriate antibiotic use was 1.55 times of the ones with appropriate use (P<0.001). Risk factors included antibiotic prophylaxis (OR=2.929), medication for surgery (OR=2.44), long hospital stay (OR=1.021 for every prolonged day) and regional factors. Protection factor was in tertiary hospital (OR=0.510).

CONCLUSION

Inappropriate antibiotic use could add 55% unnecessary cost on inpatients. Efforts to control misuse of antibiotics such as regulating antibiotic prophylaxis and medication for surgery, and decreasing length of stay should be pursued.

Drug use evaluation of statins at Siriraj Hospital, 2008

Statins are commonly used for lipid reduction. There is no significant difference in the efficiency of each type of statins. The study of statins' efficacy shows that only generic simvastatin is cost-effective in coronary heart disease prevention.

OBJECTIVE

To determine the use and appropriateness of usage of statins in out-patients attending Siriraj Hospital in 2008.

MATERIAL AND METHOD

Medical records of all patients in Siriraj Hospital who received statins from January 1st to December 31st, 2008 were reviewed. The appropriateness of statins used was analyzed in 247 medical records based on number of risks and 10-year risk.

RESULTS

There were 105,950 patients who received statins with total value of 308 million baht in 2008. The major usages of statins were simvastatin (65%), atorvastatin (12%) and rosuvastatin (6%). However, the costs of statins were 9%, 42%, and 20% for simvastatin, atorvastatin and rosuvastatin, respectively. Analysis of 247 medical records of the patients who received statins showed that statins were appropriately used in 19.4% of cases. Inappropriate use of statins was due to not starting drugs treatment with simvastatin, or shifting from simvastatin to other statins inappropriately.

CONCLUSION

Inappropriate use of statins at Siriraj Hospital is very common. Interventions for promoting more appropriate use of statins should be implemented.

Evaluation of the frequency of venous thromboembolism prophylaxis in a selected population of patients hospitalized in nonsurgical wards. Results of the all-Poland EPID Registry

INTRODUCTION

The results of the Prophylaxis in Medical Patients with Enoxoparin (MEDENOX) trial demonstrated the benefit of thromboprophylaxis in patients hospitalized because of acute heart failure, respiratory failure and rheumatic disease. Analysis of clinical practice shows that thromboprophylaxis is rarely used in these patients.

OBJECTIVES

To assess thromboprophylaxis use in a selected population of patients hospitalized in internal departments in Poland.

PATIENTS AND METHODS

Between the years 2002 and 2006, 14,707 hospitalized patients were included into the EPID Registry. The study population, selected for the purpose of this analysis, involved 5246 patients (mean age 71, 95% CI: 70.6 -71.4 years), reported by 60 internal wards, who met the entry criteria of the MEDENOX study. Patients receiving long-term antithrombotic treatment and patients with indications for initiating antithrombotic treatment were not enrolled.

RESULTS

Thromboprophylaxis was administered in 63% of patients. The average duration of thromboprophylaxis was 8.1 days (95% CI: 7.8-8.4). In the group of patients admitted to the intensive care unit thromoprophylaxis was administered in 81% of cases compared with 58% in nonsurgical departments (p < 0.0001). Low-molecular-weight heparins were used in 93% of patients receiving prophylaxis. The risk of hemorrhage (9.5%) and lack of indications for thromboprophylaxis (27%) according to the physicians were the main reasons for not using prophylaxis. The frequency of thromboprophylaxis use varied from 35% to 89% between different regions of Poland. Hemorrhagic complications were reported in 0.8% of patients receiving prophylaxis.

CONCLUSIONS

Administration of thromboprophylaxis in the MEDENOX-like population is of great importance from an epidemiological point of view because this patient group accounts for 31% of in-patients. Thromboprophylaxis is underused with large differences between regions, which should be improved by an adequate educational program for physicians from internal wards.

Dimensionality reduction for knowledge discovery in medical claims database: application to antidepressant medication utilization study

Data mining, through its capacity to discover knowledge embedded in large databases to improve organizational decision-making, has the potential to contribute to efficiencies and cost savings in the increasingly costly healthcare industry. One important aspect of the methods of mining medical databases includes reducing dimensionality through feature selection. Traditionally feature selection is accomplished through stepwise regression, which tends to produce an unnecessarily high number of "significant" variables. This paper applies a filter-based feature selection method using inconsistency rate measure and discretization, to a medical claims database to predict the adequacy of duration of antidepressant medication utilization. Compared to traditional stepwise logistic regression, which selected seven variables from a total of nine potential explanatory variables to characterize patients with inadequate antidepressant medication utilization, the filter-based method selected two variables (age and number of claims) to achieve a similar prediction accuracy. This comparison suggests it may be feasible and efficient to apply the filter-based feature selection method to reduce the dimensionality of healthcare databases.

Trends in number of consultations and antibiotic prescriptions for respiratory tract infections between 1999 and 2005 in primary healthcare in Kalmar County, Southern Sweden

BACKGROUND. Respiratory tract infections (RTIs) comprise the most common indication for consulting a general practitioner and obtaining an antibiotic prescription.

OBJECTIVE

To study changes in the number of visits, diagnoses, and antibiotic prescriptions for RTI in primary healthcare during the period 1999-2005.

DESIGN

A retrospective, descriptive, population-based study of electronic patient records. Setting. County of Kalmar in southeastern Sweden.

PATIENTS

Patients visiting primary healthcare units in Kalmar County for an RTI between 1 July 1999 and 31 December 2005.

MAIN OUTCOME MEASURES

RTI diagnoses, antibiotic prescriptions, age groups.

RESULTS

A total of 240 447 visits for RTI made between 1999 and 2005 were analysed. The yearly consultation rates for the diagnoses acute tonsillitis and AOM decreased by 12% and 10%, respectively (p = 0.001). Of all patients consulting for an RTI diagnosis, 45% received antibiotics. Of all prescribed antibiotics, 60% were for phenoxymethylpenicillin (PcV) and 18% doxycycline. Amoxicillin or amoxicillin + clavulanic acid was prescribed to a lesser extent. The proportion of patients obtaining an antibiotic prescription was almost constant over time (44-46%). The prescriptions of doxycycline showed increasing values (NS). The prescriptions of remaining antibiotics decreased significantly especially for patients up to middle age.

CONCLUSION

This large population study, comprising more than six years of observations, showed the number of primary healthcare patients receiving an RTI diagnosis decreased during the period 1999-2005, but the proportion of patients receiving an antibiotic prescription remained the same. The large seasonal variations indicate a need for further interventions to decrease antibiotic use for RTIs.

[Intravenous antimicrobial use among different hospital in Chile during 2005]

Intravenous antimicrobial consumption has not been evaluated previously in Chile. In order to know this consumption (in DDD per 100 bed days), associated factors and antimicrobial control systems across the country, a questionnaire was sent to evaluate these features during 2005. A total of 29 public hospitals and private clinics answered this poll, 20 belonging to the public health system (69%). Only 48.1% declared to have an independent antimicrobial committee and 17.2% allowed unrestricted antimicrobial use. Glycopeptides and carbapenems were the most regulated compounds (75.9 and 82.8%, respectively). Antimicrobial controls systems were more frequently declared among public hospitals and only non-public hospitals permitted free use of antimicrobials. Global consumption reached 59.98 DDD per 100 bed-days, with beta-lactams representing 74.3% of this consume (44.57 DDD per 100), and cephalosporins 43% (25.78 DDD per 100). Chloramphenicol, penicillin G and cloxacillin use was significantly higher among public hospitals. The opposite was observed for imipenem-cilastatin, linezolid, cefuroxime and caspofungin with higher consumes observed among non-public hospitals. In a multivariate analysis, increased cefazolin use was independently associated with sites allowing unrestricted use, and ciprofloxacin consumption with non-public hospitals. Institutions with decreased susceptibility to imipenem-cilastatin among non-fermentative gram negative bacilli showed a higher use of this compound and linezolid consumption paralleled vancomycin-resistant enterococci prevalence. It is necessary to reinforce governmental regulations about antimicrobial use issued during 1999.

"Doing the yellows" -- analysis of medication review processes by different clinicians in long term care

Medication regimens in long term care are intermittently revised through the participation of multiple clinicians, different institutions, through time. Such revisions have potential to result in inconsistencies and errors. Periodic revisions are undertaken to address these. We examined these review tasks, as performed by clinicians, from a broad professional spectrum that consisted of nursing consultants, a nurse care manager, a pharmacist and a pharmacy technician.

A computer program for estimating the re-transformed mean in heteroscedastic two-part models

The population of health care costs is typically skewed, heteroscedastic, and may include zero costs. Without proper accounting for these special distributional features, resulting prediction may be biased, and wrong inferences about the distribution of patients' health care costs may be made. Welsh and Zhou [A.H. Welsh, X.H. Zhou, Estimating the retransformed mean in a heteroscedastic two-part model, J. Stat. Plan. Inference 136 (2006) 860-881] proposed a semi-parametric regression model, which addressed these special features. In this paper we developed a software program to implement this statistical method, which would provide better prediction of health care costs for clinical researchers. Our program computed two mean estimators, their asymptotical standard deviation, confidence interval, and optional bootstrap confidence interval. Our program included user-friendly interactive mode and more efficient and flexible batch mode. It was written in free statistical computing language R and could be run on a wide variety of platforms.

Comparison of methods of handling missing data in individual patient data meta-analyses: an empirical example on antibiotics in children with acute otitis media

What is the influence of various methods of handling missing data (complete case analyses, single imputation within and over trials, and multiple imputations within and over trials) on the subgroup effects of individual patient data meta-analyses? An empirical data set was used to compare these five methods regarding the subgroup results. Logistic regression analyses were used to determine interaction effects (regression coefficients, standard errors, and p values) between subgrouping variables and treatment. Stratified analyses were performed to determine the effects in subgroups (rate ratios, rate differences, and their 95% confidence intervals). Imputation over trials resulted in different regression coefficients and standard errors of the interaction term as compared with imputation within trials and complete case analyses. Significant interaction effects were found for complete case analyses and imputation within trials, whereas imputation over trials often showed no significant interaction effect. Imputation of missing data over trials might lead to bias, because association of covariates might differ across the included studies. Therefore, despite the gain in statistical power, imputation over trials is not recommended. In the authors' empirical example, imputation within trials appears to be the most appropriate approach of handling missing data in individual patient data meta-analyses.

Drug prescribing pattern at the medical outpatient clinic of a tertiary hospital in southwestern Nigeria

PURPOSE

Assessment of drug use patterns with World Health Organization (WHO) Drug Use Indicators is becoming increasingly necessary towards promoting rational drug use in the developing countries. This study aimed at assessing the drug prescription pattern at the Medical Outpatient Clinic (MOP), University College Hospital, Ibadan, using some WHO core drug use indicators.

METHODS

One thousand four hundred and forty-seven patient encounters were reviewed prospectively over a 2-month period. Data were collected from patient case files immediately following consultation in each of the seven subspecialty clinics at the MOP. Prescribed medications were then reviewed for some drug use indicators including cost of medications. Cost was based on the current hospital pharmacy drug-pricing list.

RESULTS

One thousand three hundred and seven (90.3%) prescriptions from 1447 patient encounters were reviewed. One hundred and forty (9.7%) encounters did not have prescriptions written out. The overall average number of drugs prescribed was 3.2 +/- 1.47. Average percentage of drugs prescribed by generic names was 49.5% +/- 31.2, while average percentage of drugs prescribed from the hospital essential drug list was 96% +/- 14.0. The average cost of medications to patients/day was N = 126.0 +/- 136.0 approximately $0.9 (USD). Results varied between subspecialties.

CONCLUSION

The low percentage prescription of drugs by their generic name is responsible for the high cost of drugs to patients. Drug use studies are a necessary tool for assessing prescribing patterns in hospitals, recognizing areas for improvement and improving drug prescribing practices in these facilities.

Dynamic in prescribing antipsychotic drugs during five year period (2001-2005) in the Psychiatric Hospital Vrapce, Zagreb, Croatia

Aim of this study was to determine changes in prescribing antipsychotics during 5 year period in Psychiatric Hospital VrapEe. Data about type of antipsychotic medication, ward and gender were collected for all patients receiving antipsychotics on 1st of October. During 5 year period decrease in prescribing classical antipsychotics was observed while prescribing of atypical antipsychotics has shown increase. There was an increase in number of patients treated with combination of antipsychotics, while number of patients treated with clozapine remained the same. It was noticed that female patients were more often treated with atypical antipsychotics. Data for forensic and emergency ward was analyzed separately and trends similar to hospitals were noticed here. Rationalizing use of antipsychotics can decrease cost of treatment, decrease negative effects of antipsychotics and consequently improve the treatment. Through systematic studies of this type positive progress and changes in the prescribing of antipsychotics are possible.