The Impact of the Long-term Care Homes Act and Public Reporting on Physical Restraint and Potentially Inappropriate Antipsychotic Use in Ontario's Long-term Care Homes

BACKGROUND

We report on the impact of two system-level policy interventions (the Long-Term Care Homes Act [LTCHA] and Public Reporting) on publicly reported physical restraint use and non-publicly reported potentially inappropriate use of antipsychotics in Ontario, Canada.

METHODS

We used interrupted time series analysis to model changes in the risk-adjusted use of restraints and antipsychotics before and after implementation of the interventions. Separate analyses were completed for early ([a] volunteered 2010/2011) and late ([b] volunteered March 2012; [c] mandated September 2012) adopting groups of Public Reporting. Outcomes were measured using Resident Assessment Instrument Minimum Data Set (RAI-MDS) data from January 1, 2008 to December 31, 2014.

RESULTS

For early adopters, enactment of the LTCHA in 2010 was not associated with changes in physical restraint use, while Public Reporting was associated with an increase in the rate (slope) of decline in physical restraint use. By contrast, for the late-adopters of Public Reporting, the LTCHA was associated with significant decreases in physical restraint use over time, but there was no significant increase in the rate of decline associated with Public Reporting. As the LTCHA was enacted, potentially inappropriate use of antipsychotics underwent a rapid short-term increase in the early volunteer group, but, over the longer term, their use decreased for all three groups of homes.

CONCLUSIONS

Public Reporting had the largest impact on voluntary early adopters while legislation and regulations had a more substantive positive effect upon homes that delayed public reporting.

Comparison of Prescribing Patterns Before and After Implementation of a National Policy to Reduce Inappropriate Alprazolam Prescribing in Australia

IMPORTANCE

Benzodiazepines have been a common target for policy interventions to curtail inappropriate use, with mixed results. To reduce alprazolam misuse, in February 2017, Australia delisted the 2-mg tablet strength from public subsidy, eliminated refills, and reduced the pack size from 50 tablets to 10 tablets.

OBJECTIVE

To describe changes in alprazolam dispensing, prescribing, and poisonings associated with the implementation of a new policy to reduce inappropriate prescription of alprazolam in Australia.

DESIGN, SETTING, AND PARTICIPANTS

This interrupted time series analysis and cross-sectional study included data from a 10% sample of Australian people who received publicly subsidized dispensing claims and prescribing approvals for alprazolam from January 1, 2015, to December 31, 2018, and all calls to a poison information service involving alprazolam from February 1, 2015, to October 31, 2018. Autoregressive error models were used to quantify changes over time and compare patterns of use before and after the intervention. Data analyses were conducted from November 2018 to May 2019.

EXPOSURE

Implementation of the policy change on February 1, 2017.

MAIN OUTCOMES AND MEASURES

Monthly trends in alprazolam prescribing approvals and dispensings, quarterly trends in telephone calls involving alprazolam to a poison information service, and patterns of prescribing and dispensing before and after the intervention.

RESULTS

From 2015 to 2018, there were 71 481 alprazolam dispensings to 6772 people. After the intervention, overall dispensing decreased by 51.2% (95% CI, 50.5%-51.9%) and prescribing approvals increased by 17.5% (95% CI, 13.0%-22.2%). Overall, the proportion of dispensing of packs of 51 to 100 tablets increased from 5776 of 24 282 dispensings (23.8%) to 4888 of 10 676 dispensings (45.8%) (risk difference [RD], 22.0% [95% CI, 19.4%-24.6%]) and dispensing of packs of more than 100 tablets increased from 1029 of 24 282 dispensings (4.2%) to 1774 of 10 676 dispensings (16.6%) (RD, 12.4% [95% CI, 10.6%-14.2%]). Among people receiving their first alprazolam prescription, initiation with packs of 10 tablets or fewer increased from 16 of 1127 people (1.4%) before the intervention to 139 of 589 people (23.6%) after the intervention (RD, 22.2% [95% CI, 18.7%-25.7%]). Alprazolam treatment initiation with packs of more than 50 tablets also increased from 63 of 1127 people (5.6%) before the intervention to 144 of 589 people (24.4%) after the intervention (RD, 18.9% [95% CI, 15.1%-22.6%]). During 1 year before the intervention, patients received a median (interquartile range [IQR]) total of 250 (50-600) tablets and median (IQR) total combined tablet strength of 188 (50-550) mg. During 1 year after the intervention, people were dispensed less alprazolam, with a median (IQR) total of 200 (50-500) tablets and median (IQR) total combined tablet strength of 120 (30-360) mg. There was little change in poisoning calls involving alprazolam.

CONCLUSIONS AND RELEVANCE

This study found that after the policy intervention, subsidized alprazolam use decreased, but the increase in prescribing approvals placed additional burden on prescribers. Even after the intervention, most people who were dispensed alprazolam were still receiving treatment contrary to best-practice recommendations. Furthermore, the poison information center data suggested that people were still being dispensed the 2-mg tablet strength, presumably as nonsubsidized (ie, private) prescriptions.

Impact of State Regulations on Initial Opioid Prescribing Behavior in Rhode Island

The opioid epidemic presents an urgent public health problem. Rhode Island has enacted comprehensive rules to address primary prevention of opioid overdose. This study evaluates the efficacy of those regulations in altering prescribing behavior, specifically regarding the initial prescription. Using data extracted from the Rhode Island Prescription Drug Monitoring Program (PDMP), before and after the publication of updated acute pain management regulations, we studied the rate of opioid prescribing using statistical process control (SPC) charts and found that the rate of prescribing unsafe doses of opioids, more than 30 morphine milligram equivalents (MMEs) per day or more than 20 doses to opioid naïve patients, decreased significantly.

Doctors, drugs of dependence and discipline: a retrospective review of disciplinary decisions in New Zealand, 1997-2016

AIM

To describe disciplinary cases for inappropriate prescribing of drugs of dependence by doctors in New Zealand, 1997-2016.

METHODS

A retrospective analysis of disciplinary decisions to describe characteristics of cases (setting, drugs, outcome) and doctors (sex, specialty, years since qualification).

RESULTS

There were 25 disciplinary decisions involving 24 doctors. Disciplined doctors were mostly male (19;76%), working in general practice (19;76%), and older (mean 24 years in practice). Pharmacists were the most common source of notification to the authorities (6;24%); medical colleagues reported only four (16%). The alleged misconduct often involved behaviour in addition to inappropriate prescribing. In all cases the doctor was found guilty of professional misconduct. Penalties were severe: six doctors were removed from practice, 11 were suspended, and of the remainder all but one had restrictions on practice imposed. In many decisions there was no patient harm documented.

CONCLUSION

Disciplinary cases for inappropriate prescribing of drugs of dependence by doctors in New Zealand are not common, but the consequences can be dire. The role of discipline in doctors with drug dependence is unclear.

Serious Ethical Violations in Medicine: A Statistical and Ethical Analysis of 280 Cases in the United States From 2008-2016

Serious ethical violations in medicine, such as sexual abuse, criminal prescribing of opioids, and unnecessary surgeries, directly harm patients and undermine trust in the profession of medicine. We review the literature on violations in medicine and present an analysis of 280 cases. Nearly all cases involved repeated instances (97%) of intentional wrongdoing (99%), by males (95%) in nonacademic medical settings (95%), with oversight problems (89%) and a selfish motive such as financial gain or sex (90%). More than half of cases involved a wrongdoer with a suspected personality disorder or substance use disorder (51%). Despite clear patterns, no factors provide readily observable red flags, making prevention difficult. Early identification and intervention in cases requires significant policy shifts that prioritize the safety of patients over physician interests in privacy, fair processes, and proportionate disciplinary actions. We explore a series of 10 questions regarding policy, oversight, discipline, and education options. Satisfactory answers to these questions will require input from diverse stakeholders to help society negotiate effective and ethically balanced solutions.

Federal Bill Would Limit Opioid Scrips for Acute Pain

The proposed three-day limit on opioid prescriptions for acute pain would be one of the more impactful provisions for pain doctors and their patients. Exceptions would include prescriptions for chronic pain, cancer care, hospice or end-of-life care, and pain treatment that's part of palliative care.

Physician conviction for prescription related deaths: How will this affect the opioid debate?

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The Impact of WHO Essential Medicines Policies on Inappropriate Use of Antibiotics

BACKGROUND

Inappropriate overuse of antibiotics contributes to antimicrobial resistance (AMR), yet policy implementation to reduce inappropriate antibiotic use is poor in low and middle-income countries.

AIMS

To determine whether public sector inappropriate antibiotic use is lower in countries reporting implementation of selected essential medicines policies.

MATERIALS AND METHODS

Results from independently conducted antibiotic use surveys in countries that did, and did not report implementation of policies to reduce inappropriate antibiotic prescribing, were compared. Survey data on four validated indicators of inappropriate antibiotic use and 16 self-reported policy implementation variables from WHO databases were extracted. The average difference for indicators between countries reporting versus not reporting implementation of specific policies was calculated. For 16 selected policies we regressed the four antibiotic use variables on the numbers of policies the countries reported implementing.

RESULTS

Data were available for 55 countries. Of 16 policies studied, four (having a national Ministry of Health unit on promoting rational use of medicines, a national drug information centre and provincial and hospital drugs and therapeutics committees) were associated with statistically significant reductions in antibiotic use of ≥20% in upper respiratory infection (URTI). A national strategy to contain antibiotic resistance was associated with a 30% reduction in use of antibiotics in acute diarrheal illness. Policies seemed to be associated with greater effects in antibiotic use for URTI and diarrhea compared with antibiotic use in all patients. There were negative correlations between the numbers of policies reported implemented and the percentage of acute diarrhoea cases treated with antibiotics (r = -0.484, p = 0.007) and the percentage of URTI cases treated with antibiotics (r = -0.472, p = 0.005). Major study limitations were the reliance on self-reported policy implementation data and antibiotic use data from linited surveys.

CONCLUSIONS

Selected essential medicines policies were associated with lower antibiotic use in low and middle income countries.

[MEDICAL CANNABIS]

The cannabis plant has been known to humanity for centuries as a remedy for pain, diarrhea and inflammation. Current research is inspecting the use of cannabis for many diseases, including multiple sclerosis, epilepsy, dystonia, and chronic pain. In inflammatory conditions cannabinoids improve pain in rheumatoid arthritis and:pain and diarrhea in Crohn's disease. Despite their therapeutic potential, cannabinoids are not free of side effects including psychosis, anxiety, paranoia, dependence and abuse. Controlled clinical studies investigating the therapeutic potential of cannabis are few and small, whereas pressure for expanding cannabis use is increasing. Currently, as long as cannabis is classified as an illicit drug and until further controlled studies are performed, the use of medical cannabis should be limited to patients who failed conventional better established treatment.

Professional misconduct: the case of the Medical Board of Australia v Tausif (occupational discipline)

In 2014, the Australian Capital Territory Civil and Administrative Appeals Tribunal (ACAT) made a finding of professional misconduct against a Canberra general practitioner working in two bulk-billing medical practices established by a corporate medical practice service company, Primary Health Care Limited (Medical Board of Australia v Tausif (Occupational Discipline) [2015] ACAT 4). This column analyses that case, particularly in relation to the ACAT finding that the practitioner's professional misconduct was substantially contributed to by an unsafe system of care, specifically, the failure of Primary Health Care to provide supervision and mentoring for clinicians working at its medical centres. The case highlights the professional pressures carried by general practitioners who practise medicine within the framework of corporate bulk-billing business models. The column also examines the related issue of general practitioner co-payments in Australia and their impact on business models built around doctors purportedly characterised as independent contractors, bulk-billing large numbers of patients each day for short consultations.

[Impact of a Decree on ACE inhibitors/ARBs in cardiovascular secondary prevention in the Lazio Region (Central Italy): a pre-post analysis]

OBJECTIVES

to evaluate the effect of the 2010 legal decree (DCA) in the Lazio Region (Central Italy), promoting appropriateness on use of agents acting on the renin-angiotensin system, and limiting use of angiotensin II receptor blockers (ARBs) within this drug group to levels below 30%.

SETTING AND PARTICIPANTS

two cohorts of incident patients with diagnosis of cardiovascular disease (CVD) were enrolled from the regional hospital information system: the first cohort included patients discharged during the 12 months before DCA (35,917 patients), and the second one patients discharged during the 12 months after DCA (35,491 patients).

DESIGN

the first prescriptions of angiotensin- converting enzyme inhibitors (ACEIs) and ARBs in the 30 days after discharge were collected from the drug claims registry. The trends of monthly prescription proportions for the two drug groups were compared through a segmented regression analysis.

MAIN OUTCOMES MEASURES

comparison between the pre- and post-DCA periods, distinguishing between prescription made by hospital physicians and by general practitioners, and between naïve and prevalent users.

RESULTS

proportion of patients with CVD treated with ACEIs/ARBs after discharge was 50% in both pre-DCA (35,917 patients) and post-DCA (35,491 patients) cohorts, with the same share of ACEIs (60%) and ARBs (40%). ARB proportions met the threshold only for hospital prescriptions. Among naïve users, the target was met for both hospital physicians and general practitioners.

CONCLUSIONS

the specific DCA has not led to an overall improvement in the appropriateness of prescribing of ACEIs/ARBs in secondary cardiovascular prevention. However, there is a suitable prescription choice for naïve patients and when the drug is dispensed in hospital pharmacies.

What we know, and don't know, about the impact of state policy and systems-level interventions on prescription drug overdose

BACKGROUND

Drug overdose deaths have been rising since the early 1990s and is the leading cause of injury death in the United States. Overdose from prescription opioids constitutes a large proportion of this burden. State policy and systems-level interventions have the potential to impact prescription drug misuse and overdose.

METHODS

We searched the literature to identify evaluations of state policy or systems-level interventions using non-comparative, cross-sectional, before-after, time series, cohort, or comparison group designs or randomized/non-randomized trials. Eligible studies examined intervention effects on provider behavior, patient behavior, and health outcomes.

RESULTS

Overall study quality is low, with a limited number of time-series or experimental designs. Knowledge and prescribing practices were measured more often than health outcomes (e.g., overdoses). Limitations include lack of baseline data and comparison groups, inadequate statistical testing, small sample sizes, self-reported outcomes, and short-term follow-up. Strategies that reduce inappropriate prescribing and use of multiple providers and focus on overdose response, such as prescription drug monitoring programs, insurer strategies, pain clinic legislation, clinical guidelines, and naloxone distribution programs, are promising. Evidence of improved health outcomes, particularly from safe storage and disposal strategies and patient education, is weak.

CONCLUSIONS

While important efforts are underway to affect prescriber and patient behavior, data on state policy and systems-level interventions are limited and inconsistent. Improving the evidence base is a critical need so states, regulatory agencies, and organizations can make informed choices about policies and practices that will improve prescribing and use, while protecting patient health.

Disciplinary proceedings for inappropriate prescription of opioid medications by medical practitioners in Australia (2010-2014)

An analysis of 32 cases reported between July 2010 and September 2014 by professional disciplinary tribunals in New South Wales and Victoria against medical practitioners found guilty of inappropriately prescribing Sch 8 medications (mainly opioids) and Sch 4 drugs (mainly benzodiazepines) demonstrated, among others, a lengthy delay between the occurrence of the miscreant conduct and the conclusion of disciplinary proceedings. The study also raised questions about the appropriateness of utilising common criminal law theories of punishment and deterrence by non-judicial tribunals.

[Responsibility for prescribing and monitoring an act transfusion and safety blood transfusion]

The act to transfuse is a prescription following basic rules similar to drug prescriptions. If harm happens, potentially linked with this prescription, the harm's responsibility is borne by the physician, the paramedics, the care organization but by the supplier laboratory too. The setting of good practice rules consistent with science data at the time when the act is performed, the respect of the patient's rights and the quality of supplied products will be assessed during the expertise. Under restorative responsibility, it is necessary to previously establish a direct and certain causation between the litigious act and the harm to enforce the vicarious liability. Nowadays, legal precedents grant a larger protection to more and more numerous victims, enhancing the field of the fault with the appeal to assumption of fault. At the same time, the lawmaker himself promulgated objective conditions of compensation for many categories of victims of medical risk from which transfused people are part. The law of March the 4th of 2002 went one step closer devoting a new foundation of compensation: national solidarity.

Frailty: a key indicator to minimize inappropriate medication in older people

Older populations are more likely to have multiple co-morbid diseases that require multiple treatments, which make them a large consumer of medications. As a person grows older, their ability to tolerate medications becomes less due to age-related changes in pharmacokinetics and pharmacodynamics often heading along a path that leads to frailty. Frail older persons often have multiple co-morbidities with signs of impairment in activities of daily living. Prescribing drugs for these vulnerable individuals is difficult and is a potentially unsafe activity. Inappropriate prescribing in older population can be detected using explicit (criterion-based) or implicit (judgment-based) criteria. Unfortunately, most current therapeutic guidelines are applicable only to healthy older adults and cannot be generalized to frail patients. These discrepancies should be addressed either by developing new criteria or by refining the existing tools for frail older people. The first and foremost step is to identify the frail patient in clinical practice by applying clinically validated tools. Once the frail patient has been identified, there is a need for specific measures or criteria to assess appropriateness of therapy that consider such factors as quality of life, functional status and remaining life expectancy and thus modified goals of care.