American Hospital Formulary Service Research Articles

Tertiary drug information sources for treatment and prevention of COVID-19.

To evaluate tertiary drug information databases in terms of scope, consistency of content, and completeness of COVID-19 drug information. Five electronic drug information databases: Clinical Pharmacology, Lexi-Drugs, AHFS DI (American Hospital Formulary Service Drug Information), eFacts and Comparisons, and Micromedex In-Depth Answers, were evaluated in this cross-sectional evaluation study, with data gathered from October 2021 through February 2022. Two study investigators independently extracted data (parallel extraction) from each resource. Descriptive statistics were primarily used to evaluate scope (i.e., whether the resource addresses use of the medication for treatment or prevention of COVID-19) and completeness of content (i.e., whether full information is provided related to the use of the medication for treatment or prevention of COVID-19) based on a 10-point scale. To analyze consistency among resources for scope, the Fleiss multi-rater kappa was used. To analyze consistency among resources for type of recommendation (i.e., in favor, insufficient evidence, against), a two-way mixed effects intraclass coefficient was calculated. A total of 46 drug monographs, including 3 vaccination monographs, were evaluated. Use of the agents for treatment of COVID-19 was most frequently addressed in Lexi-Drugs (73.9%), followed by eFacts and Comparisons (71.7%), and Micromedex (54.3%). The highest overall median completeness score was held by AHFS DI followed by Micromedex, and Clinical Pharmacology. There was moderate consistency in terms of scope (kappa 0.490, 95% CI 0.399-0.581, p<0.001) and recommendations (intraclass correlation coefficient 0.518, 95% CI 0.385-0.651, p<0.001). Scope and completeness results varied by resource, with moderate consistency of content among resources.

Off-label use information in electronic drug information resources.

To compare electronic drug information resources for scope, completeness, and consistency of off-label uses information, and to group resources into tiers based on these endpoints. An evaluation study of six electronic drug information resources (Clinical Pharmacology, Lexi-Drugs, American Hospital Formulary Service Drug Information, Facts and Comparisons Off-Label, Micromedex Quick Answers, and Micromedex In-Depth Answers) was conducted. All off-label uses for the top 50 prescribed medications, by volume, were extracted from all resources and used to determine scope (i.e., whether the resource listed the use). Fifty randomly selected uses were then evaluated for completeness (i.e., whether the entry cited clinical practice guidelines, cited clinical studies, provided a dose, described statistical significance, and described clinical significance) and consistency (i.e., whether the resource provided the same dose as the majority). A sample of 584 uses was generated. The largest number of listed uses was in Micromedex In-Depth Answers (67%), followed by Micromedex Quick Answers (43%), Clinical Pharmacology (34%), and Lexi-Drugs (32%). The highest scoring resources for completeness were Facts and Comparisons Off-Label (median score 4/5), Micromedex In-Depth Answers (median score 3.5/5), and Lexi-Drugs (median score 3/5). Consistency with the majority in terms of dosing was highest for Lexi-Drugs (82%), Clinical Pharmacology (62%), Micromedex In-Depth Answers (58%), and Facts and Comparisons Off-Label (50%). The top-tiered resources for scope were Micromedex In-Depth and Quick Answers. For completeness, the top-tiered resources were Facts and Comparisons Off-Label and Micromedex In-Depth Answers. Lexi-Drugs and Clinical Pharmacology were the most consistent in dosing.

US drug shortages compared to the World Health Organization's Model List of Essential Medicines for Children: A cross-sectional study.

To describe US drug shortages affecting medications on the 2019 World Health Organization (WHO) Model List of Essential Medicines for Children (EMLc). Drug shortage data from January 2014 to December 2019 were obtained from the University of Utah Drug Information Service. Shortage data for drugs on the EMLc were analyzed for the type of drug, American Hospital Formulary Service category, reason for the shortage, duration of the shortage, marketing status (generic vs brand name), and whether the agent was a single- or multisource drug. From 2014 to 2019, a total of 209 drug shortages impacted medications on the EMLc, of which 77 (36.8%) remained unresolved by 2019. Of all active shortages, 13 (6.2%) began before 2014. Resolved shortages had a median duration of 5.9 months (interquartile range [IQR], 3.6-13.2 months) while active shortages had a median duration of 18.3 months (IQR, 10.9-33.5 months; P ≤ 0.0001). The therapeutic categories most impacted by drug shortages were anti-infective agents (27.3%), central nervous system agents (12.9%), and antineoplastic agents (11.0%). The reason for the shortage was not reported in 46.4% of cases. When a reason was provided, the most common reason was manufacturing problems (29.2%) followed by supply/demand mismatch (15.8%). US drug shortages affected many medications on the WHO EMLc. Future studies should examine the global shortage climate and implications for patient care.

Use of Palliative Care Among Commercially Insured Patients With Metastatic Cancer Between 2001 and 2016.

Early palliative care, concomitant with disease-directed treatments, is recommended for all patients with advanced cancer. This study assesses population-level trends in palliative care use among a large cohort of commercially insured patients with metastatic cancer, applying an expanded definition of palliative care services based on claims data. Using nationally representative commercial insurance claims data, we identified patients with metastatic breast, colorectal, lung, bronchus, trachea, ovarian, esophageal, pancreatic, and liver cancers and melanoma between 2001 and 2016. We assessed the annual proportions of these patients who received services specified as, or indicative of, palliative care. Using Cox proportional hazard models, we assessed whether the time from diagnosis of metastatic cancer to first encounter of palliative care differed by demographic characteristics, socioeconomic factors, or region. In 2016, 36% of patients with very poor prognosis cancers received a service specified as, or indicative of, palliative care versus 18% of those with poor prognosis cancers. Being diagnosed in more recent years (2009-2016 v 2001-2008: hazard ratio [HR], 1.8; P < .001); a diagnosis of metastatic esophagus, liver, lung, or pancreatic cancer, or melanoma (v breast cancer, eg, esophagus HR, 1.89; P < .001); a greater number of comorbidities (American Hospital Formulary Service classes > 10 v 0: HR, 1.71; P < .001); and living in the Northeast (HR, 1.43; P < .001) or Midwest (v South: HR, 1.39; P < .001) were the strongest predictors of shorter time from diagnosis to palliative care. Use of palliative care among commercially insured patients with advanced cancers has increased since 2001. However, even with an expanded definition of services specified as, or indicative of, palliative care, < 40% of patients with advanced cancers received palliative care in 2016.

Medication use and driving patterns in older drivers: preliminary findings from the LongROAD study

BackgroundThe potential for impaired driving due to medication use can occur at any age, though older adults are more likely to take multiple prescribed medications and experience side effects that may affect driving ability. The purpose of this study was to characterize the relationship between medications and driving safety behaviors.MethodsData for this study came from the five-site Longitudinal Research on Aging Drivers (LongROAD) project. Participants were active drivers, age 65–79 years at enrollment, and patients at one of the 5 participating sites. Medication names and doses were obtained at baseline based on the “brown-bag review” method. Medications were coded using the American Hospital Formulary Service system. Driving data were collected by a GPS accelerometer installed in the study participants’ main vehicles.ResultsMedication data were available for 2949 (98.6%) of the 2990 participants, and 2898 (96.9% of all participants) had both medication data and at least 30 recorded days of driving. The median number of medications taken per study participant was seven, with a range of 0–51. Total number of medications was significantly associated with a higher rapid deceleration rate. Certain medication classes were significantly associated with other driving outcomes, including central nervous system agents (more speeding events), hormones and gastrointestinal medications (more rapid decelerations), electrolytes (fewer rapid decelerations), and antihistamines (greater right to left turn ratio).ConclusionsOlder adult drivers are taking large quantities of prescription and non-prescription medications that may affect their driving safety. Certain medication classes are associated with potentially adverse driving patterns, such as speeding and rapid decelerations, while others are associated with potentially protective maneuvers, such as right hand turning. Further research is warranted to identify and mitigate potential adverse effects of such medications on driving safety in older adults.

PCN250 PATTERNS AND PREDICTORS OF PAIN MEDICATION PRESCRIPTIONS AMONG BREAST CANCER PATIENTS IN OFFICE-BASED SETTINGS IN THE US

Pain is a significant problem in patients with breast cancer. This study examined the prescribing practices of pain medications and factors associated with their prescriptions, with an emphasis on opioid prescribing, among office-based visits by women with breast cancer in the US. This retrospective cross-sectional study used the National Ambulatory Medical Care Survey (NAMCS) data from 2011-2016. The study included women (age>=18 years) with primary diagnosis of breast cancer identified using the International Classification of Diseases (ICD-9-CM and ICD-10-CM) codes. Pain medications were identified using American Hospital Formulary Service classification and Multum Lexicon codes. Weighted descriptive analysis examined the national level prescribing practices of pain medications in breast cancer, while multivariable logistic regression evaluated the factors associated with prescription of pain medications and opioids. Overall, there were (95% CI:19.29-28.60) outpatient visits for breast cancer during the study period. Pain medications were prescribed in 27.12 % (19.28-34.96) of these office visits; with opioids prescribed in 15.16% (8.75-21.57) and non-opioids in 17.13% (12.46-21.80) of the visits. Black race [OR=1.99 (1.18-3.35)], having Medicaid or other state-based program as payment source [OR=2.35 (1.16-4.77)], receiving adjuvant therapy [OR=4.82 (3.15-7.37)], visiting general/family practice physician [OR=2.13 (1.20-3.78)], were associated with greater likelihood of receiving pain medications; while patients in South region [OR=0.34 (0.12-0.97)] were associated with lower likelihood. Among the patients receiving pain medications, those in the Northeast [OR=0.16 (0.05-0.56)], Midwest [OR=0.13 (0.03-0.50)] and South [OR=0.16 (0.05-0.56)] regions were less likely to receive opioid prescriptions than patients residing in the West region. Patients receiving adjuvant therapy [OR=1.80 (1.01-3.22)] were more likely to be prescribed opioid medications. One in seven office visits by women with breast cancer involved opioids. Various demographic and provider characteristics are associated with prescription of pain medications and opioids. More research is needed to evaluate long-term consequences of opioid use in breast cancer.

Are shots or squats utilized more often in the 4 years prior to knee replacement surgery?

Purpose: Exercise therapy is strongly recommended as a core treatment for knee osteoarthritis, though recent studies show an increase in utilization of medications including opioids over the past 10 years in the general population. The recommendation for corticosteroid injections is conditional or neutral in most guidelines, but their use is common in clinical practice. Some clinicians advocate the use of the latter immediately prior to exercise in order to improve exercise tolerance. Little is known about utilization of either of these interventions in the Military Health System for knee osteoarthritis. The purpose of this study was to compare utilization rates, to include order and timing, of two common interventions, corticosteroid injection and exercise therapy, delivered 4 years prior to knee replacement surgery. We also examined the relationship between order and timing of each intervention with the fill of an opioid prescription. Methods: We identified all eligible TRICARE beneficiaries that underwent a knee replacement surgical procedure in either a military or civilian hospital, where TRICARE was the payer, for a 3-year period from 1 January 2016 through 31 December 2018. We used the Military Health System Data Repository which is a single-payer data repository capturing all medical care at the person-level, whether it occurs in a military or civilian hospital all around the world. We identified all persons with a current procedural terminology (CPT) code for a knee replacement surgical procedure. We also abstracted all CPT codes that reflected CSI and therapeutic exercise. We ensured that these procedure codes were present with knee-related International Classification of Disease (ICD) 9th and 10th revision codes. We also utilized the Pharmacy Data Transaction Service (PDTS) with MDR to identify all opioid prescription fills using the American Hospital Formulary Service therapeutic class codes 280808 and 280812. We identified all healthcare utilization in any setting (military or civilian clinic) for the full 4-year period prior to the knee replacement procedure (1 January 2013 through 30 December 2018). We reported means, medians, and frequency counts for each variable, and chi-square with 95% confidence intervals for odds ratio calculations. Results: Out of 54,422 unique persons that underwent a total knee replacement surgery during the surveillance period, 16,999 (31.2%) received at least 1 CSI (mean [SD] = 4.6 [4.5]), while 9668 (17.8%) received at least 1 ET session (mean [SD] = 10.0 [13.4]). Only 7379 had both CSI and ET (13.6%), but in the majority of cases (72.5%) there was more than 60 days between the CSI and the ET session. The first CSI occurred a mean of 729 days (2 years) before surgery, whereas the first ET session occurred a mean of 598 days (1.6 years) before surgery. In patients that received both CSI and ET, receiving a CSI before receiving ET was associated with higher odds of also filling at least 1 opioid prescription (OR = 1.46; 95CI 1.32 to 1.61). The results were not different based on whether care occurred in a military or civilian hospital setting. Conclusions: In this cohort across a large health system, CSI was utilized as an intervention at a rate almost double that of ET for individuals with knee osteoarthritis prior to joint replacement. When patients did receive both interventions, 60.2% of the time the CSI was administered 60 or more days before the ET, perhaps outside the window of optimal relief from the injection. These Results challenge claims of guideline-adherent care occurring within the Military Health System. Future research is necessary to better understand clinical decision-making that is guiding the use of these interventions within this health system.

Outpatient Pharmacy Prescriptions During the First Year Following Serious Combat Injury: A Retrospective Analysis.

Limited research has analyzed the full range of outpatient medication prescription activity following serious combat injury. The objectives of this study were to describe (1) outpatient medication prescriptions and refills during the first 12months after serious combat injury, (2) longitudinal changes in medication prescriptions during the first-year postinjury, and (3) patient characteristics associated with outpatient prescriptions. This was a retrospective analysis of existing health and pharmacy data for a random sample of U.S. service members who sustained serious combat injuries in the Iraq and Afghanistan conflicts, 2010-2013 (n=381). Serious injury was defined by an Injury Severity Score (ISS) of 9 or greater. These patients typically participate in military rehabilitation programs (eg, amputation care) where prescription medications are essential. Data sources were the Expeditionary Medical Encounter Database for injury-specific data, the Pharmacy Data Transaction Service for outpatient medication prescriptions and refills, and the Military Health System Data Repository for diagnostic codes of pain and psychological disorders. Military trauma nurses reviewed casualty records to identify types of injuries. Using the American Hospital Formulary Service Pharmacologic-Therapeutic Classification system, clinicians identified 13 categories of prescription medications (eg, opioid, psychotherapeutic, immunologic) for analysis. Multivariable negative binomial and logistic regression analyses evaluated significant associations between independent variables (eg, blast injury, traumatic brain injury [TBI], ISS, limb amputation, diagnoses of chronic pain, or psychological disorders) and prescription measures (ie, number or category of medication prescriptions). We also describe longitudinal changes in prescription activity postinjury across consecutive quarterly intervals (91days) during the first-year postinjury. During the first-year postinjury, patients averaged 61 outpatient prescriptions, including all initial prescriptions and refills. They averaged eight different categories of medications, primarily opioid, immunologic, gastrointestinal/genitourinary, central nervous system (CNS), nonopioid analgesic, and psychotherapeutic medications (representing 82% of prescriptions) during the first year. Prescription activity generally declined across quarters. There was still substantial prescription activity during the fourth quarter, as 79% of patients had at least one prescription. From 39 to 49% of patients had fourth-quarter prescriptions for opioid, CNS, or psychotherapeutic medications. Longitudinally, we found that 24-34% of patients had an opioid, CNS, or psychotherapeutic prescription during each of the final three quarters. In multivariable analysis, ISS, limb amputation (particularly bilateral amputation), and diagnoses of chronic pain and post-traumatic stress disorder (PTSD) were associated with significantly higher counts of individual and multiple medication prescriptions. TBI was associated with significantly lower numbers of prescriptions for certain medications. This is one of the first studies to provide a systematic analysis of outpatient medication prescriptions following serious combat injury. The results indicate substantial prescription activity from multiple medication categories throughout the first-year postinjury. Diagnoses of chronic pain, PTSD, and limb amputation and ISS were associated with significantly higher counts of prescriptions overall and more prescription medication categories. This study provides initial evidence to better understand medication prescription activity following serious combat injury. The results inform future research on medication prescription practices and planning for rehabilitation.

Association Between Sex and Opiate and Benzodiazepine Prescription Among Patients With CKD: Research Letter.

Background:Opiate and benzodiazepine use is associated with increased mortality and poorer transplant outcomes in patients with chronic kidney disease (CKD).Objective:To determine the predictors of opiate and benzodiazepine prescription in people with kidney disease.Design:Cross-sectional, observational study.Setting:Outpatient clinics at Kingston Health Sciences Centre or at affiliated sites as of June 2017.Patients:Individuals with CKD being treated at clinics or with various dialysis modalities at Kingston Health Sciences Centre and affiliated sites.Measurements:The total number of regular opioid and benzodiazepine prescriptions was recorded for each patient. Patients were stratified based on clinical (eg, dialysis modality) and demographic (sex, age, diabetes mellitus [DM], ethnicity) characteristics, as elicited below.Methods:We evaluated opiate and benzodiazepine use by chart review in the following patient groups: conventional hemodialysis (HD) (n = 359), home hemodialysis (HHD) (n = 21), peritoneal dialysis (PD) (n = 95), patients attending the multidisciplinary chronic kidney disease clinic (MCKDC) (n = 322), and kidney transplant (KT) recipients (n = 176). Opiates and benzodiazepines were classified according to the American Hospital Formulary Service system. Patients were also stratified as white (n = 855), indigenous (n = 66), or all others (n = 48).Results:The mean age was 66.2 ± 14.9 years, 602 (61.9%) were men, and 439 (45.1%) had DM. Opiates were prescribed to 223 patients (22.9%), most frequently to HD (32.3%), followed by MCKDC (20.8%), HHD (19.0%), PD (14.7%), and KT (12.5%) (P < .001). The independent predictors of opiate prescription included DM (odds ratio [OR], 1.9; 95% confidence interval [CI], 1.4-2.6; P < 0.001), conventional HD (vs all other treatment modalities) (OR, 1.8; 95% CI, 1.3-2.5; P < .001), and female sex (OR, 1.4; 95% CI, 1.0-1.9; P = .041) after adjustment for age and ethnicity (R2 = 0.037, P < .001). Benzodiazepines were prescribed to 106 patients (10.9%), most frequently to HD (15.9%), followed by HHD (9.5%), KT (9.1%), MCKDC (7.5%), and PD (7.4%) (P = .005). The independent predictors of benzodiazepine use included female sex (OR, 2.3; 95% CI, 1.5-3.4; P < .001) and dialysis modality (excluding MCKDC and KT) (OR, 1.8; 95% CI, 1.2-2.8; P = .006) after adjustment for ethnicity, DM, and age (R2 = 0.027, P < .001).Limitations:We were not able to ascertain the indication for prescription of these drugs or patient adherence.Conclusions:Women with kidney disease are significantly more likely to be prescribed opiates and benzodiazepines than men with kidney disease. Further research is required to determine whether these medications contribute to increased morbidity and mortality in women with kidney disease.Trial Registration:This manuscript does not meet the criteria for requiring registration or a statement of written consent from study participants. The previous submission of this manuscript already made mention of Research Ethics Board approval.

Drug Utilization Evaluation of Two Broad-Spectrum Antimicrobials: Cefepime and Piperacillin/Tazobactam in a Teaching Hospital in Tabriz, Iran

Background: The inappropriate use of antibiotic leads to microbial resistance, nosocomial infections and increased hospital costs. The present study was designed to evaluate DUE (Drug utilization evaluation) of cefepime and piperacillin-tazobactam drugs consumption patterns. Methods: This study was a descriptive and cross–sectional which performed 2014 on 140 hospitalized patients in Sina hospital Tabriz, Iran. Demographic data, duration of prescription, dose, dosage adjustment in renal impairment and accompanied prescribed antibiotics were extracted from medical files. UpToDate and American Hospital Formulary Service (AHFS) drug information 2012 were considered as standards of rational prescribing. Data analysis was performed by SPSS 18 software. Results: In 77.4% and 90% of the prescribed doses of cefepime and piperacillin-tazobactam for patients with guideline. The most common antibiotic administered with cefepime was ciprofloxacin (37 cases). In 21 patients, cefepime dosage should have been adjusted according to renal impairment, whereas it has done only in 16 (22.9%) patients. Culture was done in 60 (85.8%) cases. In 22(31.4%) patients, the result of culture was negative. Drug dosage and indication were appropriate in 34 (48%). The most common antibiotic administered with Piperacillin/tazobactam was vancomycin (45 cases). In 9 patients, Piperacillin/tazobactam dosage should have been adjusted according to renal impairment and it has done. Culture was done in 53 (75.8%) cases. In 9(12.8%) patients, the result of culture was negative. Conclusion: The results showed that there was an injudicious use of cefepime and piperacillin/ tazobactam at our hospital, evidenced by the significant number of inappropriate empiric prescriptions and drug modifications

A population-based study of prescribing trends in a potentially vulnerable paediatric population from 1999 to 2012.

There is a limited understanding of paediatric medication prescribing trends and patterns, thus poorly positioning decision-makers to identify quality and safety concerns related to medication use. The objective of this study was to determine overall medication prescribing trends and patterns among children receiving Ontario Drug Benefits over a thirteen-year period in the province of Ontario, Canada. Administrative health databases housed within the Institute for Clinical Evaluative Sciences (ICES), Ontario, Canada, were used to identify outpatient prescriptions dispensed from 1999 to 2012 through a publicly funded programme to children ≤18 years of age. Medications were classified according to the American Hospital Formulary Service Pharmacologic-Therapeutic Classification system. Descriptive statistics were used to summarize prescribing patterns. This study identified 457 037 children who were dispensed a new prescription between 1999 and 2012. About 56% received their first prescription before 6.5 years of age, and 85% of the children in this study were from families who received social assistance. The most commonly prescribed drugs were antiinfectives (56.1%). Prescriptions for several central nervous system agents, including antipsychotics and agents for attention-deficit/hyperactivity disorder, increased across the study period. Changes in prescribing patterns within opioids, hormones and autonomic agents were noted. The results suggest that historically, prescribing trends have shifted with public policy, pharmaceutical marketing and diagnostic patterns, thus identifying them as a possible tool to measure the impact of policydriven practice changes. Anti-infective prescribing increased markedly with the global H1N1 pandemic. Pharmaceutical marketing, formulary decisions and diagnostic trends may affect the prescribing of ADHD medications globally. The prescribing of codeine-containing products and medroxyprogesterone appeared to fluctuate in response to important publications in the medical literature, and the use of epinephrine syringes increased after public policy changes in the province of Ontario. The steady rise in the use of medications whose long-term effects in children are unknown, such as antipsychotics and proton pump inhibitors, identifies areas in need of future research. This study presents the first overview of Canadian prescribing trends for children, the majority of which are of low socioeconomic status and represent a potentially vulnerable population. Our analysis suggests that future research is required to determine whether prescribing trends could be used as indicators of policy effectiveness, pharmacovigilance and diagnostic trends.

Comorbid Insomnia and Sleep Apnea are Associated with Greater Downstream Health Care Utilization and Chronic Opioid Use after Arthroscopic Hip Surgery

Background: There is a relationship between sleep, pain, and chronic opioid utilization. This has been poorly explored in general, and especially in patients undergoing orthopaedic surgery. Fewer studies have investigated this relationship based on a sleep diagnosis present both before and after surgery. Objectives: To identify the association between insomnia and sleep apnea and downstream opioid use and medical utilization (visits and cost) in the 2 years following arthroscopic hip surgery. Study Design: A retrospective cohort. Setting: The US Military Health System. Methods: This was a consecutive cohort of individuals undergoing hip arthroscopy in the Military Health System (MHS). Medical utilization data were abstracted from the MHS Data Repository between 2003 and 2015, representing 1 year prior and 2 years after surgery for every individual. Sleep disorder diagnoses (insomnia and sleep apnea) were identified using International Classification of Disease codes, and opioid utilization was determined from pharmacy data based on American Hospital Formulary Service codes 280808 and 280812. Sleep disorders present before surgery were used as predictors in multivariate logistic regression, and sleep disorders present after surgery were examined for associations with the outcomes using the Chi-square tests. The dependent variables in both cases were downstream medical utilization (costs, visits, and opioid use). Results: Of 1870 eligible patients (mean age 32.3 years; 44.5% women), 165 (8.8%) had a diagnosis of insomnia before surgery and 333 (17.8%) after surgery; whereas 93 (5.0%) had a diagnosis of apnea before surgery and 268 (14.3%) after surgery. A diagnosis of insomnia before surgery predicted having at least 3+ opioids prescriptions after surgery (adjusted odds ratio, 1.97 [95% confidence interval, 1.39, 2.79]) and greater downstream total medical visits and costs in the 2 years after surgery. However, the number of individuals with a diagnosis of insomnia or apnea after surgery more than doubled, and was significantly associated with chronic opioid use, all-cause medical and all hip-related medical downstream visits and costs in the 2 years after surgery. Limitations: The use of observational data and claims data are only as good as how it was entered. Conclusions: Sleep disorders prior to surgery predicted chronic opioid use and medical utilization after surgery. However, a much higher rate of individuals had sleep apnea and insomnia present after surgery, which were significantly associated with chronic opioid use and greater total and hip-related medical utilization (visits and costs). Screening for sleep disorders prior to surgery may be important, but an even higher rate of sleep disorders may be developed after surgery, and continued screening after surgery may have greater clinical merit. Assessing quality of sleep during perioperative management may provide a unique opportunity to decrease pain and chronic opioid use after surgery. Key words: Pain, opioid use, insomnia, sleep apnea, orthopaedic surgery, military medicine, health care utilization Pain Physician 2019

Specialty Drug Price Trends in the Federal 340B Drug Discount Program.

The federal 340B Drug Discount Program provides access to significant drug price discounts for health care organizations in the United States that serve a disproportional share of disadvantaged patients. To analyze trends over a 10-year period (2006~2016) in the price of specialty drugs, contrasting the market price with the price paid under the 340B program. Pharmacy purchase records, including the 340B drug price and the wholesale acquisition cost (WAC), were collected from a 340B-contract pharmacy group in Southern California between 2006 and 2016. Records were used to calculate price changes in the annual average price paid. The average price was calculated as the weighted price, using purchasing volume for each year as weights. Separate time series of year-to-year price changes were created by therapeutic class using the American Hospital Formulary Service Therapeutic Classification system. The 340B price growth rate patterns were similar to the profile of the WAC prices over time across all drug classes. The overall drug price growth rate per year over 10 years for WAC prices was 15% and 10% for 340B prices. For specialty drug classes, the average growth rates per year were 14% for the WAC price and 6% for the 340B price. For certain specialty drug classes, such as antineoplastic and antiretroviral drugs, the 340B price inflation rates were significantly lower than the WAC price inflation rates after 2013. The price inflation of specialty drugs exceeds the rate of inflation in the Consumer Price Index for prescription drugs. The 340B price shows a similar inflation pattern as the WAC price over time in the specialty drug categories. This study is 1 of 3 research projects that comprise Lee's dissertation. Funding to support Lee's dissertation research was provided as an unrestricted fellowship from PharMedQuest Pharmacy Services. Chang is employed by PharMedQuest Pharmacy Services, which provided the dataset for analysis. Lee reports grants from PharMedQuest Pharmacy Services, unrelated to this study. McCombs has nothing to report.

Evaluation of Clinical Compendia Used for Medicare Part D Coverage Determinations for Off-label Prescribing in Dermatology

When making coverage determinations for off-label prescribing, Medicare Part D recognizes 2 compendia: the American Hospital Formulary Service (AHFS) Drug Information and the DRUGDEX Information System. Deficiencies in the accuracy and completeness of these compendia could result in coverage denials for necessary, effective, evidence-based treatments. To evaluate these compendia for dermatologic conditions, with a focus on less common conditions that often require systemic treatment. This cross-sectional study was conducted from July 1, 2018, through September 30, 2018. To identify diseases for which dermatologists may often need access to off-label systemic treatments, a list of 22 chronic, noninfectious, nonneoplastic diseases with at least 4 systemic therapies (including 1 in the first-line therapies and less than 25% approved by the US Food and Drug Administration) were selected for evaluation. With use of Treatment of Skin Disease, 5th Edition, a list of first-, second-, and third-line medications was created, including the level of evidence for each disease. A search of AHFS and DRUGDEX compendia was performed to evaluate for inclusion of the evidence-based therapies. In addition, the references cited in the compendia to justify inclusion of the therapy were examined qualitatively. Percentage of treatment options included in each compendium, stratified by level of evidence and position on the therapeutic ladder. Concordance between the 2 compendia was assessed using Cohen κ. Overall, 73 of 238 treatments (30.7%) evaluated were included in either compendium. Among individual diseases, 10 of 22 (45%) had 1 or fewer treatments included in the DRUGDEX compendium and 15 of 22 (68%) had 1 or fewer treatments included in the AHFS compendium. Discrepancies in which a medication was included in one compendium but not in the other compendium occurred for 53 of the 238 medications (22.3%) evaluated. Literature use did not follow a discernible pattern and was often based on decades-old sources. The findings suggest that treatment options listed in these compendia are incomplete, outdated, idiosyncratic, and unpredictable. To ensure that patients can access treatments for their disease, it appears that policies to reduce the reliance on these compendia for coverage determinations should be developed.

1879. A Point Prevalence Study of Antibiotic Utilization in 61 Geographically Diverse Acute Care Hospitals (2017)

BackgroundAntibiotic utilization for geographically diverse areas can be difficult to obtain. The purpose of this study was to characterize patterns of US antibiotic use over a defined period to provide comparative data for benchmarking and to assist with identifying antibiotic stewardship opportunities.MethodsData were obtained as part of a larger study evaluating antibiotic time out practices. Participating institutions submitted de-identified patient-level antibiotic use data from a single day (between October 16, 2017 and November 17, 2017). Indication, expected duration, and antibiotic stop dates were documented. Antibiotics were classified by American Hospital Formulary Service (AHFS) therapeutic category and evaluated to identify duplicate anti-anaerobic, anti-MRSA, and AHFS classes. Hospital teaching status and US Census region were recorded.ResultsA total of 6,184 courses of therapy (8,996 individual antibiotics) were evaluated from 61 hospitals. Sixty-four percent of therapy courses submitted were from academic medical centers. Distribution by census region was Midwest (44.7%), Northeast (15.11%), South (23.2%), and West (16.9%). Over half (53.7%) of therapy was empiric and 33.4% was directed. Sixty-six percent of courses did not include a stop date within the electronic medical record. Twelve drugs comprised 80% of total antibiotic use. Percentage of antipseudomonal use was similar across regions, but anti-MRSA therapy was higher in the South and Midwest. Duplicate β-lactam therapy and duplicate anti-anaerobe therapy were identified in 1.5% of total courses (each). Duplicate anti-MRSA therapy occurred in 0.29% of therapy courses. Three percent of patients developed a Clostridium difficile infection during their hospitalization.ConclusionVancomycin and piperacillin–tazobactam were the most common antibiotics used which is consistent with other analyses, but anti-anaerobic use as a percentage of overall use was higher than expected. Duplicate anti-anaerobe and β-lactam therapy is less frequent, but still represents an opportunity for stewardship. Antipseudomonal and anti-MRSA agents represent two key categories for stewardship given the high percentage of use. The addition of a stop date to the antibiotic order presents an opportunity to improve overall utilization. Disclosures All authors: No reported disclosures.

Approved and Off-Label Use of Prescribed Psychotropic Medications among Federal Canadian Inmates.

To examine psychotropic medication prescription practices in federal Canadian penitentiaries. 468 files were drawn from a purposive sample of thirteen Canadian federal institutions representing the five regions, different security levels, and male and female designated facilities. Information on the names of all psychotropic medications prescribed, indications for use, dosage, frequency, and route of administration was retrieved. Designation of approved or off-label use of medications was determined by consulting: (1) the Health Canada (2016) Drug Product Database, (2) the Canadian Compendium of Pharmaceuticals and Specialties 2016, and (3) the American Hospital Formulary Service Drug Information 2016. Prescription rates were examined by gender, Indigenous ancestry, drug class, institutional infractions, and current offence. 36.2% of prescriptions for psychotropic medication were coded as 'off-label'. Anxiolytic/hypnotics drugs were the psychotropic drugs most commonly used for off-label purposes. There were no differences in the prevalence of approved versus off-label prescriptions based on Indigenous ancestry or gender, and no pattern of elevated off-label prescription practices for offenders involved in institutional misconducts or those sentenced for the most serious crimes. The rates of prescribing 'off-label' psychotropic medication are not elevated relative to other correctional settings or to rates cited in Canadian surveys conducted in the community.

Off-label prescribing for children with chronic diseases in Nigeria; findings and implications

ABSTRACTBackground: Prescribing medicines in an off-label manner for children with chronic conditions is sparsely documented, even more so among developing countries. This needs addressing. The objective of this research was to investigate the extent of off-label prescribing among children with epilepsy, asthma, and sickle cell anaemia in Nigeria.Methods: Prescriptions for children ≤16 years documented in their case files that attended paediatric clinics in Lagos, Nigeria, for these three conditions between January and October 2015, were reviewed retrospectively to extract data on the medicines prescribed. British National Formulary for children and American Hospital Formulary Service Drug information were used as references.Results: 477 patients received 1746 prescriptions. Off-label prescriptions were seen in 7.7% of prescriptions, related to dose (93; 68.9%), indication (22; 16.3%), and age (20; 14.8%). Nervous system (525; 30.1%) and anti-infective (441; 25.2%) medicines were the most prescribed but only 9.5% and 8.2% of the respective prescriptions were off-label. Children with epilepsy received the most number (94; 69.6%) of off-label prescriptions. The three chronic conditions did not associate significantly with the category of off-label medicine prescribed (p = 0.925).Conclusion: Off-label prescribing for children with epilepsy, asthma and sickle cell anaemia occurs. Encouragingly, the overall rate appears low in Nigeria.

Review of Nonformulary Medication Approvals in an Academic Medical Center

The Joint Commission requires hospitals to formally review formulary medications at least annually based on new clinical information. Although review of nonformulary medication (NFM) use is not required, frequent and inappropriate use of NFMs has the potential to increase hospital costs, negatively affect quality of care, and increase medication errors. Limited resources may restrict an institution's ability to review NFM use in addition to the required annual formulary review. NFM use at Brigham and Women's Hospital (BWH) was reviewed to provide insight on how to best direct an NFM review that is both effective and efficient. How an NFM review may negatively affect cost, quality of care, and medication errors is also inferred. All approved NFM requests between 2009 and 2012 from Brigham and Women's Hospital's computerized provider order entry system were extracted and categorized according to the American Hospital Formulary Service (AHFS) Pharmacologic-Therapeutic Classification System. Of the 15,356,016 new medication orders, there were 223,266 NFM approvals for 433 unique NFMs. NFMs were categorized into 91 AHFS, 14 combination, and 4 "Others" classes. Twenty-five AHFS Classes accounted for approximately the top 90% of all NFM approvals, and the top 2 NFMs in each class accounted for a majority of the NFM approvals. Only a few classes of medications and a few medications within each class accounted for most of the NFM use at BWH. Targeting review of the most frequently used NFMs in each class may be a feasible strategy to reviewing NFMs annually that is both effective and efficient in optimizing formulary benefits.

Antimuscarinic Medication Use in Elderly Patients with Overactive Bladder.

Antimuscarinic medications are the first-line pharmacological treatment for overactive bladder (OAB); however, little is known about the utilization pattern of antimuscarinic agents in elderly patients with OAB. This study examined the prevalence and predictors of antimuscarinic medication prescribing in elderly patients with OAB, using national ambulatory survey data. This cross-sectional study utilized the 2009-2010 National Ambulatory Medical Care Survey and the outpatient component of the National Hospital Ambulatory Medical Care Survey. The study included patients aged ≥65years diagnosed with OABbased on the International Classification of Diseases. Antimuscarinic medications were operationally defined using the American Hospital Formulary Service classification and identified using Multum Lexicon codes. Descriptive statistics using sampling weights were used to estimate the prevalence of antimuscarinic medication prescription, while multivariable logistic regression within the conceptual framework of the Anderson Behavioral Model was used to identify the factors associated with antimuscarinic medication prescription in elderly patients with OAB. According to the national surveys, 2.18 million (95% confidence interval [CI] 1.62-2.75) elderly outpatient visits were made for OAB, of which 0.90 million (41.43%) visits involved prescribing of antimuscarinic medications. The most frequently prescribed drugs were solifenacin (14.25%), oxybutynin (10.50%), and tolterodine (6.89%). Multivariable analysis revealed that patients ≥85years of age (odds ratio [OR] 3.50, 95% CI 1.23-9.92) were more likely to receive antimuscarinic medications,and the South region (OR 2.78, 95% CI 1.01-7.66) increased the likelihood of receiving antimuscarinic medications in elderly patients with OAB. This study found that antimuscarinic medications are commonly prescribed for elderly patients with OAB and there is variation in antimuscarinic use across age and region.

Evaluation of Subcutaneous Phenobarbital Administration in Hospice Patients.

Phenobarbital is used in hospice and palliative care to treat refractory symptoms. In end-of-life care, Food and Drug Administration approved routes of administration may be unreasonable based on patients' status. In these cases, phenobarbital may be administered subcutaneously for symptom management. However, according to the American Hospital Formulary Service, subcutaneous administration of commercially available injectable phenobarbital is cautioned due to possible skin reactions. This study evaluates the tolerability of phenobarbital administered subcutaneously. Of 69 patients and 774 distinct subcutaneous phenobarbital injections, 2 site reactions were recorded (2.9% of patients; 0.3% of injections). Both were mild, grade 1 reactions. Each patient continued to receive subcutaneous phenobarbital via newly placed ports with no additional reactions. Based on these findings, phenobarbital appears to be well tolerated when administered subcutaneously.