Changes In Prescribing Research Articles

Incremental Hemodialysis: What We Know so Far.

Traditionally, patients that develop progressive chronic kidney disease in need of kidney replacement therapy are prescribed thrice weekly in-center hemodialysis sessions at the beginning of therapy. This empiric prescription is based on historic trials that were comprised of mostly prevalent patients. Incremental hemodialysis is the process of performing <3 sessions of dialysis per week or limiting dialysis dose by duration at the initial onset of treatment to provide a more gradual transition, mimicking the progressive nature of kidney disease. Adding clearance contributions from residual kidney function is the standard of care with peritoneal dialysis but has not routinely been employed with hemodialysis. Accounting for residual kidney function accompanied by improvement in adjuvant pharmacotherapy, such as newer potassium binding agents and dietary modification, can augment dialytic clearances and allow for an incremental approach. Utilizing incremental dialysis has been associated with both preserving residual kidney function as well as improving patient quality of life. Barriers to this approach include concerns regarding patient acceptance of dialysis prescription changes, adherence to therapy, and provider factors that would require a restructuring of the current thrice weekly hemodialysis rubric. Candidacy for incremental therapy has shown the best outcomes when urea clearances exceed 3 mL/min and urine volumes are >500 mL/day, although these measures have been deemed conservative. A significant amount of retrospective and registry data has been supportive of initiating incremental hemodialysis and several pilot studies have shown the feasibility of implementing such an approach. Larger, randomized control trials are needed to fully evaluate safety and efficacy to allow for more widespread acceptance of this patient-centered approach to chronic kidney disease.

Randomized controlled trial of an audit and feedback cycle to improve adherence to Choosing Wisely Canada recommendations.

Context: Choosing Wisely Canada (CWC) aims to engage healthcare providers to reduce unnecessary care. Reducing overuse of antimicrobials and antipsychotics in patients with dementia in primary care settings remains an ongoing challenge. Audit and Feedback (A&F) interventions can facilitate practice change but can be improved by understanding factors affecting the likelihood of uptake of the feedback. Objective: To assess the impact of A&F interventions to reduce unnecessary prescribing of antibiotics and antipsychotics use and evaluate whether practice changes remain stable over time. Design: Clustered randomized controlled trial. Dataset: The Manitoba Primary Care Research Network (MaPCReN), a practice-based network that includes a repository containing de-identified EMR data from over 288,000 Manitobans. Population: Primary care providers participating in MaPCReN were randomized to three A&F groups: 1) Information on the relevant CWC recommendations; 2) practice specific data along with general information regarding the CWC recommendations 3) No CWC information. Outcome Measures: Statistics demonstrating changes in target prescriptions. Multivariate regression assessed characteristics of providers with improved prescribing. Results: 182 primary care providers were evaluated, 86.3% decreased the number of target prescriptions. More providers decreased prescribing in group1 (88.9%) or group2 (94.0%) compared to the control group 3 (76.7%) (p-value 0.02). There was no statistically significant difference between practice specific feedback and generic CWC information. An average of 46 antibiotic medications per provider were prescribed for viral indications in 2014/2015. This dropped to 15 in 2016/17 and was 18 in 2018/19. An average of 3 antipsychotic medications were prescribed for patients with dementia in 2014/2015. This dropped 7% in 2016/17 and remained stable in 2018/19. There were no statistically significant provider characteristics when considering all providers with improved prescribing, but male, rural and fee for service providers were more likely to decrease prescribing greater than the mean. Conclusion: Both practice specific and generic A&F information sent directly to primary care providers by a trusted source reduced potentially unnecessary prescriptions. This supports ongoing engagement with primary care providers in practice-based research networks to improve care and promote sustained practice changes.

Emergency department diagnosis and management of constipation in the United States, 2006-2017.

Constipation is a common diagnosis in adults and children. Emergency department (ED) visits for constipation increased from 1980 to 2010. Since then, efforts have aimed to reduce resource utilization for constipation in the ED setting. Our objective is to examine contemporary ED practice patterns in the context of updated care guidelines. We conducted a cross-sectional study using the National Hospital Ambulatory Medical Care Survey from 2006 to 2017. Encounters with a constipation diagnosis were included. We examined rates of ED visits, diagnostic testing, and medication use. We also compared general and pediatric ED practice patterns for children. Approximately 1.3 million ED visits with a diagnosis of constipation occurred annually, with pediatric encounters comprising one-third of all visits. There was a 114% increase in ED visits for constipation over the study period. Urinalysis and imaging increased by 17% and 15%, respectively. Older patients were more likely to undergo diagnostic testing. No significant changes in laboratory testing, radiographs, or osmotic laxative prescriptions were observed among children. Compared to pediatric EDs, general EDs were more likely to perform CBC (29% vs. 15%) and urinalysis testing (42% vs 31%). General EDs were less likely to prescribe osmotic laxatives for children compared to pediatric EDs (26% vs. 37%). ED visits for constipation have increased significantly since 2006. Rates of diagnostic tests and prescriptions have not changed despite published evidence and guidelines that the diagnosis of constipation does not require imaging, and that the management of constipation requires consistent outpatient treatment. Opportunities exist to reduce ED resource utilization through knowledge dissemination and implementation.

CHANGES IN THE TREATMENT PLANS OF GLAUCOMA PATIENTS IN A REAL-WORLD SITUATION

OBJECTIVE: To determine the changes in glaucoma prescriptions during a single visit in real-world situation at Al-Shifa Trust Eye Hospital, Rawalpindi, Pakistan. METHODS: This cross-sectional descriptive study was conducted at Glaucoma Department of Al-Shifa Trust Eye Hospital, Rawalpindi, Pakistan from September 1st, 2015 to February 29th, 2016 after the ethical approval. Of total 876 consecutive participants, 868 were included in the study. Complete ocular examination was carried out for each subject including intraocular pressure (IOP) by Goldmann, visual field and nerve fiber analysis if it was scheduled. Ocular and systemic co-morbidities as well as ocular surgeries were also noted. Number of topical medications including anti-glaucoma and other drugs were recorded before and after their visit. The changes in anti-glaucoma medications were then categorized as unchanged, changed, added or deleted. The results were analyzed via SPSS version-24. RESULTS: A total 1600 eyes of 868 patients were included in this study. Out of 868 patients, 507 (58.41%) were males and 291 (33.52%) were in 61-70 years age group. Majority of patients (n=680/868: 78.34%) had open-angle glaucoma. Out of 1600 eyes studied, 574 (35.87%) had moderate and 556 (34.75%) had severe stage of glaucomatous optic neuropathy. During single visit, glaucoma-related prescriptions were unchanged, changed, added and deleted in 618/868 (71.20%), 84/868 (9.68%), 95/868 (10.94%) &amp; 71/868 (8.18%) patients respectively. In our study, 911/1600 (56.94%) eyes achieved target IOP ≤14 mmHg. CONCLUSION: In real-world situation, most of our glaucoma patients were stable and required no changes to their prescriptions in single visit.

Long-Stay Mood Stabilizer Use Increasing as Prescription of Antipsychotics Decreases

Abstract. This retrospective cohort analysis of claims data used logistic regression to evaluate change in antipsychotic and antiepileptic mood stabilizer prescription frequencies in Virginia nursing homes among residents with and without seizure-epilepsy between the years 2011 and 2016. Over that period, prescription of antipsychotics decreased 13.1% to 5.6% in the long-stay population, while the use of antiepileptic mood stabilizers increased significantly 27.0%, to an 8.6% prevalence rate. These gains were entirely among residents without epilepsy. African-Americans and males were at significantly increased risk for the prescription of mood stabilizers. Growth in long-stay antiepileptic mood stabilizer use is unrelated to seizure-epilepsy, as these changes in prescription occurred only among residents without seizure-epilepsy. More antiepileptic mood stabilizers are now being prescribed to nursing-home residents without epilepsy than antipsychotics in the nursing-home population overall.

Interprofessional Collaboration between ICU Physicians, Staff Nurses, and Hospital Pharmacists Optimizes Antimicrobial Treatment and Improves Quality of Care and Economic Outcome.

(1) Background: Antibiotic resistance is a worldwide health threat. The WHO published a global strategic plan in 2001 to contain antimicrobial resistance. In the following year, a workshop identified crucial barriers to the implementation of the strategy, e.g., underdeveloped health infrastructures and the scarcity of valid data as well as a lack of implementation of antibiotic stewardship (ABS) programs in medical curricula. Here, we show that interprofessional learning and education can contribute to the optimization of antibiotic use and preserving antibiotic effectiveness. We have initiated interprofessional rounds on a medical intensive care unit (MICU) with a focus on gastroenterology, hepatology, infectious diseases, endocrinology, and liver transplantation. We integrated ICU physicians, hospital pharmacists, nursing staff, and medical students as well as students of pharmacy to broaden the rather technical concept of ABS with an interprofessional approach to conceptualize awareness and behavioral change in antibiotic prescription and use. Methods: Clinical performance data and consumption figures for antibiotics were analyzed over a 10-year period from 2012 to 2021. The control period covered the years 2012–2014. The intervention period comprised the years 2015–2021, following the implementation of an interprofessional approach to ABS at a MICU of a German university hospital. Data from the hospital pharmacy, hospital administration, and hospital information system were included in the analyses. A specific electronic platform was developed for the optimization of documentation, interprofessional learning, education, and sustainability. The years 2020 and 2021 were analyzed independently due to the SARS-CoV-2 pandemic and the care of numerous COVID-19 patients at the MICU. Results: Implementation of an interprofessional ABS program resulted in the optimization of antibiotic management at the MICU. The suggestions of the hospital pharmacist for optimization can be divided into the following categories (i) indication for and selection of therapy (43.6%), (ii) optimization of dosing (27.6%), (iii) drug interactions (9.4%), (iv) side effects (4.1%), and (v) other pharmacokinetic, pharmacodynamic, and pharmacoeconomic topics (15.3%). These suggestions were discussed among the interprofessional team at the MICU; 86.1% were consequently implemented and the prescription of antibiotics was changed. In addition, further analysis of the intensive care German Diagnosis Related Groups (G-DRGs) showed that the case mix points increased significantly by 31.6% during the period under review. Accordingly, the severity of illness of the patients treated at the ICU as measured by the Simplified Acute Physiology Score (SAPS) II increased by 21.4% and the proportion of mechanically ventilated patients exceeded 50%. Antibiotic spending per case mix point was calculated. While spending was EUR 60.22 per case mix point in 2015, this was reduced by 42.9% to EUR 34.37 per case mix point by 2019, following the implementation of the interprofessional ABS program on the MICU. Through close interprofessional collaboration between physicians, hospital pharmacists, and staff nurses, the consumption of broad-spectrum antibiotics, e.g., carbapenems, was significantly reduced, thus improving patient care. In parallel, the case mix and case mix index increased. Thus, the responsible use of resources and high-performance medicine are not contradictory. In our view, close interprofessional and interdisciplinary collaboration between physicians, pharmacists, and nursing staff will be of outstanding importance in the future to prepare health care professionals for global health care to ensure that the effectiveness of our antibiotics is preserved.

Clinical and Microbiological Effects of an Antimicrobial Stewardship Program in Urology-A Single Center Before-After Study.

Antimicrobial resistance is a major public health issue caused by antibiotic overuse and misuse. Antimicrobial stewardship (AMS) has been increasingly endorsed worldwide, but its effect has been studied scarcely in urologic settings. A before-after study was performed from 2018 through 2020 to evaluate changes in antimicrobial prescription, resistance rates and clinical safety upon implementation of an AMS audit and feedback program in the Urology Department of a large German academic medical center. The primary endpoints were safety clinical outcomes: the rate of infection-related readmissions and of infectious complications after transrectal prostate biopsies. Resistance rates and antimicrobial consumption rates were the secondary endpoints. The AMS team reviewed 196 cases (12% of all admitted in the department). The overall antibiotic use dropped by 18.7%. Quinolone prescriptions sank by 78.8% (p = 0.02) and 69.8% (p > 0.05) for ciprofloxacin and levofloxacin, respectively. The resistance rate of E. coli isolates declined against ceftriaxone (−9%), ceftazidime (−12%) and quinolones (−25%) in the AMS period. No significant increase in infection-related readmissions or infectious complications after prostate biopsies was observed (p = 0.42). Due to the potential to reduce antibiotic use and resistance rates with no surge of infection-related complications, AMS programs should be widely implemented in urologic departments.

Dose tapering, increases, and discontinuity among patients on long-term high-dose opioid therapy in the United States, 2017–2019

BackgroundWhile reduced exposure to prescription opioids may decrease risks, including overdose and opioid use disorder, abrupt tapering or discontinuation may pose new risks. ObjectivesTo examine potentially unsafe tapering and discontinuation among dosage changes in opioid prescriptions dispensed to US patients on high-dose long-term opioid therapy. DesignLongitudinal observational study of adults (≥18 years) on stable high-dose (≥50 oral morphine milligram equivalents [MME] daily dosage) long-term opioid therapy during a 180-day baseline and a 360-day follow-up using all-payer pharmaceutical claims data, 2017–2019. MeasuresDosage tapering, increases, and/or stability during follow-up; sustained dosage stability, reductions, or discontinuation at the end of follow-up; and tapering rate. Patients could experience more than one outcome during follow-up. ResultsAmong 595,078 patients receiving high-dose long-term opioid therapy in the sample, 26.7% experienced sustained dosage reductions and 9.3% experienced discontinuation. Among patients experiencing tapering, 62.0% experienced maximum taper rates between > 10–40% reductions per month and 36.1% experienced monthly rates ≥ 40%. Among patients with mean baseline daily dosages ≥ 150 MME, 47.7% experienced a maximum taper rate ≥ 40% per month. Relative to baseline, 19.7% of patients experiencing tapering had long-term dosage reductions ≥ 40% per month at the end of follow-up. ImplicationsDosage changes for patients on high-dose long-term opioid therapy may warrant special attention, particularly over shorter intervals, to understand how potentially sudden tapering and discontinuation can be reduced while emphasizing patient safety and shared decision-making. Rapid discontinuation of opioids can increase risk of adverse outcomes including opioid withdrawal.

Impact of coronavirus disease 2019 epidemics on prevention and care for HIV and other sexually transmitted infections.

To assess the impact of coronavirus disease 2019 (COVID-19) epidemics on the prevention and care for HIV and other sexually transmitted infections at a major reference centre providing preventive and clinical services in Catalonia, Spain. We retrospectively compared anonymized clinical and laboratory data from March to December 2020 vs. 2019. Monthly clinical data on HIV preexposure and postexposure prophylaxis users and on adults with HIV infection were retrieved from the administrative hospital database. Monthly tests for HIV, hepatitis B and C, Treponema pallidum, Neisseria gonorrhoeae,and Chlamydia trachomatis, and plasma lipids and glucose were recovered from the laboratory database. There were less (↓28%, P = 0.003) but more advanced (mean CD4+ cells/μl 305 vs. 370, P < 0.001) HIV infections and more gonorrhoea (↑39%, P < 0.001) and chlamydia (↑37%, P < 0.001) infections in 2020 vs. 2019. In people with HIV, rates of HIV RNA less than 50 copies/ml remained stable (11 vs. 11%, P = 0.147) despite less scheduled visits (↓25%, P < 0.001). However, they had less antiretroviral prescription changes (↓10%, P = 0.018), worse plasma lipids [mean total cholesterol 190 vs. 185 mg/dl, P < 0.001;mean low-density lipoprotein (LDL) cholesterol 114 vs. 110 mg/dl, P < 0.001; mean triglycerides 136 vs. 125 mg/dl, P < 0.001; mean high-density lipoprotein (HDL) cholesterol 47 vs. 48 mg/dl, P = 006], and an excess of mortality (↑264%, P = 0.006) due in great part not only to COVID-19 but also to other causes. In our setting, COVID-19 epidemics was associated with an increase in some prevalent sexually transmitted infections, with less but more advanced HIV infections, and with worse nonvirologic healthcare outcomes and higher mortality in people living with HIV.

The Effect of the NorGeP-NH on Quality of Life and Drug Prescriptions in Norwegian Nursing Homes: A Randomized Controlled Trial.

Background: The effect of the Norwegian General Practice–Nursing Home (NorGeP–NH) criteria has never been tested on clinical outcomes in nursing home (NH) residents. We performed a cluster-randomized trial in Norwegian NHs and tested the effect of NorGeP–NH on QoL (primary outcome), medication prescriptions, and physical and mental health (secondary outcomes) for the enrolled residents; Methods: Fourteen NHs were randomized into intervention NHs (iNHs) and control NHs (cNHs). After baseline data collection, physicians performed NorGeP–NH on the enrolled residents. We assessed the difference between cNHs and iNHs in the change in primary outcome from baseline to 12 weeks and secondary outcomes from baseline to eight and 12 weeks by linear mixed models; Results: One hundred and eight residents (13 lost to follow-up) and 109 residents (nine lost to follow-up) were randomized to iNHs and cNHs, respectively. Difference in change in QoL at 12 weeks between cNHs and iNHs was not statistically significant (mean (95% CI)): −1.51 (−3.30; 0.28), p = 0.101). We found no significant change in drug prescriptions over time. Difference in depression scores between cNHs and iNHs was statistically significant after 12 weeks. Conclusions: Our intervention did not affect QoL or drug prescriptions, but reduced depression scores in the iNHs. NorGeP–NH may be a useful tool, but its effect on clinical outcomes may be scarce in NH residents. Further studies about the effectiveness of NorGeP–NH in other healthcare contexts and settings are recommended.

The Rapid Reduction of Infection-Related Visits and Antibiotic Use Among People With Cystic Fibrosis After Starting Elexacaftor-Tezacaftor-Ivacaftor.

People with cystic fibrosis (CF) routinely suffer from recurrent sinopulmonary infections. Such infections require frequent courses of antimicrobials and often involve multidrug-resistant organisms. The goal of this study was to identify real-world evidence for the effectiveness of elexacaftor-tezacaftor-ivacaftor (ELX/TEZ/IVA) in decreasing infection-related visits and antimicrobial use in people with CF. Using IBM MarketScan data, we identified 389 enrollees with CF who began taking ELX/TEZ/IVA before 1 December 2019 and were enrolled from 1 July 2019 to 14 March 2020. We also identified a comparison population who did not begin ELX/TEZ/IVA during the study period. We compared the following outcomes in the 15 weeks before and after medication initiation: total healthcare visits, inpatient visits, infection-related visits, and antimicrobial prescriptions. We analyzed outcomes using both a case-crossover analysis and a difference-in-differences analysis, to control for underlying trends. For the case-crossover analysis, ELX/TEZ/IVA initiation was associated with the following changes over a 15-week period: change in overall healthcare visit dates, -2.5 (95% confidence interval, -3.31 to -1.7); change in inpatient admissions, -0.16 (-.22 to -.10); change in infection-related visit dates, -0.62 (-.93 to -.31); and change in antibiotic prescriptions, -0.78 (-1.03 to -.54). Results from the difference-in-differences approach were similar. We show a rapid reduction in infection-related visits and antimicrobial use among people with CF after starting a therapy that was not explicitly designed to treat infections. Currently, there are >30000 people living with CF in the United States alone. Given that this therapy is effective for approximately 90% of people with CF, the impact on respiratory infections and antimicrobial use may be substantial.

Point-of-Care Synchronous Virtual Radiology Consultations for Atherosclerotic Disease in Primary Care: A Cluster-Randomized Study.

Synchronous virtual visits are an emerging model of care, and their feasibility has been demonstrated in radiology. The purpose of this study was to assess the value of point-of-care virtual radiology primary care consultations for atherosclerotic vascular disease management. In this institutional review board-approved study, 107 age- and gender-matched patients were assigned to control (n= 62) and intervention (n= 45) arms with the following inclusion criteria: (1) age > 45 years, (2) consult with a primary care physician (PCP), and (3) recent CT of the chest or abdomen demonstrating atherosclerotic calcification. In the intervention arm, virtual real-time radiology consultation with referring PCPs and patients was conducted, with review of CT images focused on the extent of vascular atherosclerosis. Patients in the control arm followed the current standard of care of PCPs' discussing relevant imaging results, if any. Thirty-one patients in the intervention arm and 31 patients in the control arm completed the study (control: 64.5% women; mean age, 68 years; intervention: 67.7% women; mean age, 67 years). Discussion of imaging findings occurred with all patients in the intervention arm (discussion with PCP and virtual consultation with radiologist) and with 45% of patients in the control arm (PCP only; P < .001). All patients in the intervention arm indicated that seeing or discussing their images improved their understanding of their disease, compared with 85% of patients in the control arm (P= .04). In the intervention arm, 10 of 31 patients (32.2%) left the visit with changes in prescriptions for statins or antihypertensive medications, compared with only 4 of 31 patients (13%) in the control arm (P= .04). Point-of-care radiology virtual visits enhance patient understanding and may influence the longitudinal management of atherosclerotic disease in primary care.

Satisfaction and effectiveness of tele-medicine in follow-up of people with epilepsy in a resource-poor setting during COVID-19

BackgroundEffectiveness of different tele-medicine strategies varies in different medical conditions. Use of basic tele-medicine strategy like mobile health (m-health) can be an effective option in different medical conditions in a resource-poor setting. AimsTo study effectiveness and satisfaction of tele-medicine among persons with epilepsy (PWE) in a developing nation during COVID-19 pandemic. MethodsPersons with epilepsy aged 18 years or more who have attended epilepsy clinic at least once physically and were asked for regular follow-up were included. A cross-sectional telephonic survey was conducted to assess effectiveness of tele-medicine over past 1 year. Satisfaction was assessed by tele-medicine satisfaction questionnaire. Result31.9% of PWE have used tele-medicine facility in last 1 year and 58.2% were unaware of the availability of such a facility. Among those who utilized tele-medicine, 95.3% were able to explain their concerns satisfactorily during tele-consultation and change in prescription was done in 42.8%. None experienced any new adverse event. Overall, more than 95% were satisfied with tele-consultation and more than 80% wanted to use it again. ConclusionEven basic tele-medicine strategies can be a very effective and satisfactory mode of follow-up for PWE in resource-poor settings. Steps should be undertaken to make people aware of the availability of such a facility.

Impacts of an Opioid Safety Initiative onUS Veterans Undergoing Cancer Treatment.

There is limited research on how the opioid epidemic and consequent risk reduction policies have affected pain management among cancer patients. The purpose of this study was to analyze how the Opioid Safety Initiative (OSI) implemented at the Veterans Health Administration affected opioid prescribing patterns and opioid-related toxicity. We performed an interrupted time series analysis of 42 064 opioid-naïve patients treated at the Veterans Health Administration for prostate, lung, breast, and colorectal cancer from 2011 to 2016. Segmented regression was used to evaluate the impact of the OSI on the incidence of any new opioid prescriptions, high-risk prescriptions, persistent use, and pain-related emergency department (ED) visits. We compared the cumulative incidence of adverse opioid events including an opioid-related admission or diagnosis of misuse before and after the OSI. All statistical tests were 2-sided. The incidence of new opioid prescriptions was 26.7% (95% confidence interval [CI] = 25.0% to 28.4%) in 2011 and increased to 50.6% (95% CI = 48.3% to 53.0%) by 2013 before OSI implementation (monthly rate of change: +3.3%, 95% CI = 1.3% to 4.2%, P < .001). After the OSI, there was a decrease in the monthly rate of change for new prescriptions (-3.4%, 95% CI = -3.9 to -2.9%, P < .001). The implementation of the OSI was associated with a decrease in the monthly rate of change of concomitant benzodiazepines and opioid prescriptions (-2.5%, 95% CI = -3.2% to -1.8%, P < .001), no statistically significant change in high-dose opioids (-1.2%, 95% CI = -3.2% to 0.9%, P = .26), a decrease in persistent opioid use (-5.7%, 95% CI = -6.8% to -4.7%, P < .001), and an increase in pain-related ED visits (+3.0%, 95% CI = 1.0% to 5.0%, P = .003). The OSI was associated with a decreased incidence of opioid-related admissions (3-year cumulative incidence: 0.9% [95% CI = 0.7% to 1.0%] vs 0.5% [95% CI = 0.4% to 0.6%], P < .001) and no statistically significant change in the incidence of opioid misuse (3-year cumulative incidence: 1.2% [95% CI = 1.0% to 1.3%] vs 1.2% [95% CI = 1.1% to 1.4%], P = .77). The OSI was associated with a relative decline in the rate of new, persistent, and certain high-risk opioid prescribing as well as a slight increase in the rate of pain-related ED visits. Further research on patient-centered outcomes is required to optimize opioid prescribing policies for patients with cancer.

Calcineurin inhibitors and related medicines: a cohort study examining England's primary care prescription changes during the COVID-19 pandemic (January 2019 to March 2021).

PurposeTo examine the impact of the COVID-19 pandemic on calcineurin inhibitors and related prescriptions for community patients in England.MethodsData from all primary-care patients who had calcineurin inhibitors prescriptions, dispensed in the community in England were included. Descriptive statistics and interrupted time series analysis over 27 months (15 months before and 12 months after 1st lockdown) was evaluated.ResultsDescriptive statistics show that mean values have declined since the pandemic’s onset. Over the 27 months: mean Tacrolimus 865,045 doses, standard deviation (SD) 76,147 doses, with 95% CI 834,923, 895,168, (min 567,508, max 1,010,900), ciclosporin 315,496 doses, SD 40,094, 95% CI 299,635, 331,356 (min 191,281, max 382,253) and sirolimus 21,384 doses, SD 2,610, 95% CI 20,352, 22,417 (min 13,022, max 26,156). Analysis of variance between the pre- and post- periods show significant variations in quantities of tacrolimus F 7.432, p = 0.012, ciclosporin F 33.147, p < 0.001 and sirolimus F 18.596, p < 0.001 (1df), mirrored in price analysis. The Interrupted Time Series (ARIMA Modelling) shows declining trends. After the pandemic's onset, a statistically significant downward trend in quantity for tacrolimus p = 0.008 is observed, with an estimated monthly decline of 14,524 doses, ciclosporin p = 0.185, with an estimated decline of 2,161 doses and sirolimus p = 0.002 with an estimated decline of 485 doses, along with declining prices.ConclusionA decrease in prescription medicines use raises concerns for the care of (renal) transplant patients. Patients are encouraged to discuss their planned care with their doctor, secure supplies and remain adherent to their medication.Graphical abstract Supplementary InformationThe online version contains supplementary material available at 10.1007/s40199-021-00431-7.

Changes in Prescribing Antithrombotic Therapy in Patients with Atrial Fibrillation in the Multidisciplinary Hospital in Volgograd from 2012 to 2020

Aim. To study the frequency of prescribing antithrombotic agents in patients with non-valvular atrial fibrillation (AF) in real clinical practice, to evaluate changes of prescriptions from 2012 till 2020.Material and methods. The medical records of inpatients (Form 003/y) with the diagnosis AF, hospitalized in the cardiological department were analyzed. According to the inclusion criteria, the patients were over 18 years of age, established diagnosis of non-valvular AF. There were two exclusion criteria: congenital and acquired valvular heart disease and prosthetic heart valves. In retrospective analysis we have included 263 case histories in 2012, 502 ones in 2016 and 524 in 2020. CHA2DS2-VASc score was used for individual stroke risk assessment in AF. The rational use of the antithrombotic therapy was evaluated according with current clinical practice guidelines at analyzing moment.Results. During period of observation the frequency of antiplatelet therapy significantly decreased from 25,5% to 5,5% (р&lt;0.001), decreased the frequency of administration of warfarin from 71,9% to 18,3% (р&lt;0.001). The frequency of use of direct oral anticoagulants increased in 2020 compared to 2016 (р&lt;0.001). For patients with a high risk of stroke anticoagulant therapy was administered in 71.8% of cases in 2012, 88.5% in 2016 and 92.5% in 2020. Before discharge from hospital majority of patients (72%) achieved a desired minimum international normalized ratio (INR) from 2.0 to 3.0 in 2012. In 2016 and 2020 an only 33% and 40.6% of patients achieved INR (2.0-3.0).Conclusion. Doctors have become more committed to following clinical guidelines during the period of the investigation. In 2020 antithrombotic therapy for atrial fibrillation was suitable according to current clinical guidelines.

Pharmaceutical care at discharge for patients with feeding tubes.

Objective: to assess and analyse a medication adaptation pathway for feeding tube administration followed by clinical pharmacists for patients at discharge, and to analyse the level of physician acceptance of the recommendations issued by pharmacists in pharmaceutical care reports to improve patient therapy. Methods: a multidisciplinary protocol for treatment adaptation to feeding tube administration at discharge was implemented in a 350-bed hospital during 2019, in which pharmacists prepared feeding tube medication-adaptation reports during pharmaceutical care visits. The number of recommendations related to adaptation of a drug to route of administration was recorded and classified as need for change of active substance or change of pharmaceutical form. Physician acceptance of pharmacist recommendations was analysed in a one-year retrospective observational study. Results: a total of 66 pharmaceutical care visits were recorded for 57 patients (1.2 visits per patient). In 47 of these 66 visits (71.2 %), at least one drug modification was required in a patient prescription, and the median number of drugs per patient needing to be modified was 2. Overall, 93 of the 489 prescribed drugs (19.0 %) required some changes to be suitable for administration via feeding tube: change of active substance in 52.7 % (49/93) of cases, and change of pharmaceutical form in 47.3 % (44/93) of cases. The physicians' level of acceptance of recommendations was 43.0 % (40/93), and change of pharmaceutical form was less accepted than change of active substance. Conclusion: the inclusion of clinical pharmacists in multidisciplinary teams leads to an improvement in adapting medication to feeding tube administration, but also shows a lack of communication or understanding of pharmacist recommendations by physicians resulting in a low rate of prescription changes.

Changes in Outpatient Opioid Prescribing During the COVID-19 Pandemic: An Interrupted Time Series Analysis.

Objectives:Changes in health care delivery during the COVID-19 pandemic may have impacted opioid prescribing. This study evaluated the impact of restrictions on in-person care on opioid prescribing in the outpatient setting. The hypothesis was that after restrictions to in-person care were implemented, there would be a reduction in the number of chronic and non-chronic opioid prescriptions.Methods:An interrupted time series analysis was conducted to compare the number of weekly opioid prescriptions between baseline (1/1/2019-3/14/2020), restriction (3/15/2020-6/6/2020), and reopening (6/7/2020-10/31/2020) periods at outpatient practices within a health system in Bronx, NY. Analyses were stratified by prescription type (chronic if the patient had been prescribed opioids for >90 days, or non-chronic).Results:For chronic opioid prescriptions, the week restrictions were implemented, there was an increase in the number of prescriptions compared to what was predicted if there had been no interruption (34.8 prescriptions, 95% CI: 8.0, 61.7). Subsequently, the weekly trend in prescribing was not different in the restriction period or in the reopening period compared to the previous time periods. For non-chronic opioid prescriptions, during the restriction period, the weekly trend in prescribing decreased compared to baseline (−5.0 prescriptions/week, 95% CI: −9.0, −1.0). Subsequently, during the reopening period, the weekly trend in prescribing increased compared to the restriction period (6.4 prescriptions/week, 95% CI: 2.2, 10.7).Conclusions:Despite abrupt restrictions on in-person care, chronic opioid prescriptions did not decrease, which is evidence that providers evolved to meet patient needs. Changes in non-chronic prescriptions are likely related to patients electing not to pursue care for acute pain or challenges with appointment availability.

Time and State Legislation Have Decreased Opioid Prescribing in Elective Foot and Ankle Surgery in the United States

Category:Other; Ankle; Ankle Arthritis; Arthroscopy; Bunion; Hindfoot; Lesser Toes; Midfoot/Forefoot; SportsIntroduction/Purpose:The opioid epidemic has focused attention on opioid overprescribing. State legislation has been enacted to reduce acute opioid prescribing. However, the impact of this legislation on elective foot and ankle surgery is largely unknown. The purpose of this study was to evaluate the impact of opioid limiting legislation on opioid prescribing in elective foot and ankle surgery.Methods:90-day perioperative opioid prescription filling in oxycodone 5-mg equivalents was identified in all patients ages 18 and older undergoing non-trauma, non-arthroplasty foot and ankle surgery from 2010 - 2019 using a commercial database. States with and without legislation were identified and opioid prescription filling before and after legislation was tabulated. Unadjusted and adjusted analyses were performed to evaluate the impact of time and state legislation on perioperative opioid prescribing in this patient population.Results:Initial and cumulative opioid prescribing decreased significantly from 2010 to 2019 (39 vs 35.7 initial and 98.1 vs 55.7 cumulative oxycodone 5-mg equivalents, p<0.001). States with legislation had larger and more significant reductions in initial and cumulative opioid prescribing compared to states without legislation over similar timeframes (41.6 to 35.1 with legislation vs 40.6 to 39.1 without legislation initial oxycodone 5-mg equivalents prescription filling volume and 87.7 to 62.8 vs 88.6 to 74.1 cumulative oxycodone 5-mg equivalents prescription filling volume, p<0.001). The figure shows state-level changes in opioid prescription filling from pre-act to post-act.Conclusion:State legislation and time have been associated with large, clinically relevant reductions in 90-day perioperative cumulative opioid prescription filling although reductions in initial opioid prescription filing have remained low. These results encourage states without legislation to enact restraints to reduce the impact of the opioid epidemic.

Changes in intravenous and oral antimicrobial prescriptions during the coronavirus disease 2019 (COVID-19) pandemic: an experience at a tertiary-care center.

Antimicrobial use during the coronavirus disease 2019 (COVID-19) pandemic at a tertiary-care center was analyzed using interrupted time-series analysis. Among intravenous antimicrobials, the use of azithromycin and third-generation cephalosporins significantly decreased during the current pandemic. Similarly, the use of oral antimicrobials, including azithromycin and fluoroquinolones, also decreased.