Differences In Prescribing Patterns Research Articles

Sex Differences in Prescription Patterns and Medication Adherence to Guideline-directed Medical Therapy Among Patients with Ischemic Stroke.

Background: Ischemic stroke is a leading cause of death and disability. Society guidelines recommend pharmacotherapies for secondary stroke prevention. However, the role of sex differences in prescription and adherence to guideline-directed medical therapies (GDMT) after ischemic stroke remains understudied. The aim of this study was to examine sex differences in prescription and adherence to GDMT at 1-year after ischemic stroke in a cohort of commercially insured patients. Methods: Using the Truven Health MarketScan database from 2016-2020, we identified patients admitted with ischemic stroke. GDMT was defined as any statin, antihypertensive, and anticoagulant prescription within 30-days after discharge. Medication adherence was estimated using the proportion of days covered (PDC) at 1-year. PDC <0.80 was used to define non-adherence. A multivariable model adjusting for covariates was performed to identify the factors associated with non-adherence at 1-year. This analysis was restricted to new users of GDMT. Results: Among 155220 patients admitted with acute ischemic stroke during the study period, 15,919 met the inclusion criteria. The mean age was 55.7 years, and 7,701 (48.3%) were women. Women were less likely prescribed statins (58.0% vs 71.8%), and antihypertensives (27.7% vs 41.8%). In this subset of patients with atrial flutter/fibrillation, women were also less likely prescribed anticoagulants (41.2% vs 45.0%). Women were more likely to be non-adherent (i.e., PDC <0.80) to statins (47.3% vs 41.6%, P<0.0001), antihypertensives (33.3% vs 32.2%, P=0.005), and the combination of both (49.6% vs 45.0%, P=0.003). On multivariable analysis, women were likely to be non-adherent to GDMT at 1-year (odds ratio 1.23, 95% confidence interval 1.08-1.41). Conclusions: In this real-world analysis of commercially insured patients with ischemic stroke, women were less likely initiated on GDMT within 30 days after discharge. Women were more likely to be non-adherent to statins and antihypertensive agents at 1-year. Future efforts and novel interventions are needed to understand the reasons and minimize these disparities.

Prescribing pattern insights from a longitudinal study of older adult inpatients with polypharmacy and chronic non-cancer pain.

The present study sought to determine the prevalence of chronic non-cancer pain (CNCP) among older adult inpatients with polypharmacy. It also aimed to analyse prescription patterns and assess the therapy adequacy and patient complexity for those with and without CNCP. This 4-year longitudinal study examined data from an exhaustive acute care hospital register on home-dwelling older adult patients (≥65) with polypharmacy. Commonly known combinations of potentially inappropriate medications were used to estimate therapy adequacy. Patient complexity was evaluated by comparing number of comorbidities and investigating physical and cognitive deficits. We determined a prevalence of CNCP of 9.7% among all older adult inpatients with polypharmacy, rising to 11.3% for those aged ≥85. Overall, CNCP patients were prescribed more drugs and had more comorbidities and physical and cognitive deficits than patients without CNCP. Older adult patients with CNCP received more analgesics, greater quantities of opioids, paracetamol and co-analgesics and elevated opioid dosages. Older adult patients with CNCP aged ≥85 received fewer analgesics, opioids, non-steroidal anti-inflammatory drugs and co-analgesics but more paracetamol. Older adult patients with CNCP were prescribed more potentially inappropriate medications involving opioids. In particular, 24.5% received an opioid and a hypnotic (benzodiazepine or Z-drug), and 8.6% received an opioid and a gabapentinoid. Observed differences in medication use between older adult inpatients with or without CNCP may be relevant for clinical practice. Potentially inadequate co-prescribing (such as hypnotics and opioids) affects a higher proportion of patients with CNCP and may have serious unintended consequences. This study describes differences in prescription patterns between people with and without chronic non-cancer pain in a large dataset of 20,422 discharges. The differences found may be relevant to clinical practice. In particular, high co-prescribing of opioids and hypnotics may have serious unintended consequences. Greater physical and cognitive deficits may indicate greater patient complexity, and appropriate interventions need to be developed to improve the management of this vulnerable patient group.

Comparison of antipsychotic drug use in children and adolescents in the Netherlands before and during the COVID-19 pandemic

This study aims to describe the patterns and trends in antipsychotic prescription among Dutch youth before and during the corona virus disease 2019 (COVID-19) pandemic (between 2017 and 2022). The study specifically aims to determine whether there has been an increase or decrease in antipsychotic prescription among this population, and whether there are any differences in prescription patterns among different age and sex groups. The study utilized the IADB database, which is a pharmacy prescription database containing dispensing data from approximately 120 community pharmacies in the Netherlands, to analyze the monthly prevalence and incidence rates of antipsychotic prescription among Dutch youth before and during the pandemic. The study also examined the prescribing patterns of the five most commonly used antipsychotics and conducted an autoregressive integrated moving average (ARIMA) analysis using data prior to the pandemic, to predict the expected prevalence rate during the pandemic. The prescription rate of antipsychotics for Dutch youth was slightly affected by the pandemic, with a monthly prevalence of 4.56 [4.50–4.62] per 1000 youths before COVID-19 pandemic and 4.64 [4.59–4.69] during the pandemic. A significant increase in prevalence was observed among adolescent girls aged 13–19 years. The monthly incidence rate remained stable overall, but rose for adolescent girls aged 13–19 years. Aripiprazole, and Quetiapine had higher monthly prevalence rates during the pandemic, while Risperidone and Pipamperon had lower rates. Similarly, the monthly incidence rates of Aripiprazole and Olanzapine went up, while Risperidone went down. Furthermore, the results from the ARIMA analysis revealed that despite the pandemic, the monthly prevalence rate of antipsychotic prescription was within expectation. The findings of this study suggest that there has been a moderate increase in antipsychotic prescription among Dutch youth during the COVID-19 pandemic, particularly in adolescent females aged 13–19 years. However, the study also suggests that factors beyond the pandemic may be contributing to the rise in antipsychotic prescription in Dutch youth.

Prescription patterns of P2Y12 inhibitors following revascularization in the United States: 2013-2018.

P2Y12 inhibitors (i.e., clopidogrel, prasugrel, or ticagrelor) are effective at reducing adverse cardiovascular outcomes post-revascularization in coronary artery disease (CAD). However, the choice of a specific P2Y12 inhibitor may vary according to the patient's characteristics, and trends in the use of different P2Y12 inhibitors are not well studied in real-world settings. The objective of this study is to determine trends in the prescription patterns of P2Y12 inhibitors in patients with CAD. We studied 137,073 patients with CAD cross-sectionally using the IBM MarketScan database (2013-2018). Patients with CAD prescribed P2Y12 inhibitors within 14 days of index revascularization were included to compare the utilization of P2Y12 inhibitors based on age and clinical characteristics. There were differences in prescription patterns by age. Among patients aged less than or equal to 65 years (N = 92,734), a continuously increased utilization of ticagrelor was observed from 13.7% to 45.6% replacing clopidogrel as the most prescribed medication by 2018. Similarly, ticagrelor was the choice of drug among patients undergoing percutaneous coronary intervention. Among the patients at high bleeding risk, clopidogrel remained the most prescribed medication with use in 50.6% of patients in 2018 in patients aged less than or equal to 65 years. Contrarily, among the older adults with age 65 or above (N = 44,339), although ticagrelor use increased with time, clopidogrel remained the most utilized drug and was used by 66.2% of patients in 2018. Additionally, clopidogrel was the preferred medication among patients with stroke history. With the increasing use of ticagrelor in real-world practice, further research is needed to observe its impact on cardiovascular outcomes.

Antibiotic prescription after tooth extraction in adults: a retrospective cohort study in Austria

BackgroundBroad spectrum antibiotics are often used for the prophylaxis of infectious endocarditis and treatment of odontogenic infections, but there are limited data related to antibiotic use and adherence to prescription guidelines. MethodsData from patients with tooth extraction between 2014 and 2018 were selected from a database of a regional health insurance fund. We created three data sets, one based on all tooth extractions, one on multiple teeth extractions, and one including only single tooth extraction. After data collection, descriptive analysis was carried out. The differences in prescription pattern of antibiotic medicine were tested by χ2 test, Student´s t-test or ANOVA.ResultsFrom 43,863 patients with tooth extraction, 53% were female, and 3,983 patients (9.1%) filled a prescription for antibiotic medicine. From 43,863 patients, 157 patients (0.4%) had endocarditis risk, but only 8 patients of these (5.1%) filled an antibiotic prescription. In total, 9,234 patients had multiple and 34,437 patients had only one tooth extraction. Patients with more than one tooth extraction received more often antibiotic treatment (10.7%) compared to those with single tooth extractions (χ2 = 36; p < 0,001). Patients with more than one tooth extraction were older, however, younger patients received antibiotics more frequently (t = 28,774, p = 0.001). There was no relationship with endocarditis risk status. Clindamycin and amoxicillin/clavulanic acid were the most frequently prescribed antibiotic medicines.ConclusionsIn this retrospective cohort study, dentists did not discriminate prophylactic antibiotic prescription with regard to endocarditis risk status. A factor influencing prescribing behaviour of antibiotic medicines was the number of extracted teeth.

Acute Headache Management for Patients with Subarachnoid Hemorrhage: An International Survey of Health Care Providers.

Severe headaches are common after subarachnoid hemorrhage. Guidelines recommend treatment with acetaminophen and opioids, but patient data show that headaches often persist despite multimodal treatment approaches. Considering an overall slim body of data for a common complaint affecting patients with SAH during their intensive care stay, we set out to assess practice patterns in headache management among clinicians who treat patients with SAH. We conducted an international cross-sectional study through a 37-question Web-based survey distributed to members of five professional societies relevant to intensive and neurocritical care from November 2021 to January 2022. Responses were characterized through descriptive analyses. Fisher's exact test was used to test associations. Of 516 respondents, 329 of 497 (66%) were from North America and 121 of 497 (24%) from Europe. Of 435 respondents, 379 (87%) reported headache as a major management concern for patients with SAH. Intensive care teams were primarily responsible for analgesia during hospitalization (249 of 435, 57%), whereas responsibility shifted to neurosurgery at discharge (233 of 501, 47%). Most used medications were acetaminophen (90%), opioids (66%), corticosteroids (28%), and antiseizure medications (28%). Opioids or medication combinations including opioids were most frequently perceived as most effective by 169 of 433 respondents (39%, predominantly intensivists), followed by corticosteroids or combinations with corticosteroids (96 of 433, 22%, predominantly neurologists). Of medications prescribed at discharge, acetaminophen was most common (303 of 381, 80%), followed by opioids (175 of 381, 46%) and antiseizure medications (173 of 381, 45%). Opioids during hospitalization were significantly more prescribed by intensivists, by providers managing higher numbers of patients with SAH, and in Europe. At discharge, opioids were more frequently prescribed in North America. Of 435 respondents, 299 (69%) indicated no change in prescription practice of opioids with the opioid crisis. Additional differences in prescription patterns between continents and providers and while inpatient versus at discharge were found. Post-SAH headache in the intensive care setting is a major clinical concern. Analgesia heavily relies on opioids both in use and in perception of efficacy, with no reported change in prescription patterns for opioids for most providers despite the significant drawbacks of opioids. Responsibility for analgesia shifts between hospitalization and discharge. International and provider-related differences are evident. Novel treatment strategies and alignment of prescription between providers are urgently needed.

Prevalence and patterns of anti-osteoporotic drug use based on 2019 real-world nationwide data in Greece.

Based on the 2019 European scorecard (SCOPE), osteoporosis is diagnosed in an estimated 683,679 individuals in Greece, with the direct cost of incident fractures being €694.7 million, although further relevant real-world data are scarce. The e-Government Center for Social Security Services prescription database, which covers almost 100% of the Greek population, was used to capture all individuals on anti-osteoporotic treatment during 2019. A total of 288,983 among 8,641,341 people, corresponding to 3.3% of the total adult Greek population, had filled at least one anti-osteoporotic prescription (6.0% and 0.36% for females and males, respectively). Prevalence of anti-osteoporotic treatment increased with age, from 0.15% in those younger than 50 to 8.6% in those older than 70years. Oral bisphosphonates were more frequently prescribed (58.8%), followed by denosumab (39.4%). Alendronate was more frequently prescribed in males and in people younger than 60years. Denosumab was more frequently prescribed in females and in people older than 60years. Selective estrogen-receptor modulators, teriparatide, and parenteral bisphosphonates accounted for 1.1%, 1.0%, and 0.02% of all prescriptions, respectively. Orthopedic surgeons (39.6%), endocrinologists (19.6%), general practitioners (19%), and rheumatologists (9.3%) prescribed the vast majority of anti-osteoporotic regimens, with significant differences in prescription patterns. The annual cost of treatment per patient increased significantly with age, being on average €323.33. Less than half of the estimated number of individuals with osteoporosis in 2019 in Greece received treatment, with the total annual cost being far less than the estimated cost of incident-fragility fractures. The impact of this undertreatment on related health care costs merits further investigation.

Difference in rural and urban Medicare prescription pattern for Parkinson’s disease in Hawai‘i

BackgroundMedical management of Parkinson’s Disease (PD) is becoming complex. Increasing evidence suggests that patients have better outcomes when they are managed by neurologists. However, access to neurologists can be limited in rural areas. Analysis of prescription pattern can provide insight into access gap rural patients face. MethodsThis retrospective observational study used National Medicare Provider Utilization and Payment Data: Part D Prescriber Public Use Files from 2013 to 2018. Query was made for levodopa, dopamine agonists and other antiparkinsonian medications. The data elements obtained included drug name, number of prescribers, prescriber specialty, number of claims, number of standardized 30-day Part D prescriptions, and number of Medicare beneficiaries in the state of Hawai‘i. Individual prescribing providers were categorized as urban or rural based on their cities of practice. Prescription patterns of urban and rural providers in Hawai‘i as well as difference in provider specialty were compared, using standardized 30-day prescriptions as the primary measure of utilization. ResultsPractice patterns differed between rural and urban areas. In rural Hawai‘i, Rytary, Rotigoitne and selegiline were rarely prescribed. Levodopa percentage was higher in urban Hawai‘i. In urban Hawai‘i, 74.4% of the prescriptions were provided by movement disorders and general neurologists. In rural Hawai'i, 25.1% of the prescriptions were written by neurologists and 74.9% by general practitioners. ConclusionsIn the state of Hawai‘i, there is an urban–rural access gap to neurologists as evidenced by Medicare prescription pattern. Further study is needed to understand the reasons for rural–urban differences in prescription patterns and their impact on outcomes.

Differences in prescription patterns between real-world outpatients with bipolar I and II disorders in the MUSUBI survey.

There is limited information available on the prescription of psychotropic agents to patients with bipolar I (BD-I) and bipolar II disorder (BD-II). The purpose of this study was to investigate the characteristics of drug therapy in BD-I and BD-II outpatients, particularly with regard to antidepressants. In 2017, the MUlticenter treatment SUrvey for BIpolar disorder in Japanese psychiatric clinics (MUSUBI) study collected data on current mental status, medications, and other factors from 2774 outpatients with BD-I or BD-II. There were significant differences in the rates of prescriptions for mood stabilizers, antipsychotics and antidepressants. Mood stabilizers and antipsychotics were prescribed at higher rates to patients with BD-I (mood stabilizers; BD-I 86.0%, BD-II 80.8%, p<0.001; antipsychotics; BD-I 61.5%, BD-II 47.8%, p<0.001), and antidepressants were prescribed at higher rates to patients with BD-II (BD-I 32.1%, BD-II 46.4%, p<0.001). The most commonly prescribed antidepressants were escitalopram for patients with BD-I and duloxetine for patients with BD-II. Selective serotonin reuptake inhibitors (SSRIs) were the most common class of antidepressants prescribed to patients with BD. With regard to combination therapy, combinations containing antidepressants were often prescribed to patients with BD-II. There was a difference in the prescription of psychotropic agents between patients with BD-I and BD-II. The outpatient prescriptions for BD in Japan were mood stabilizers and antipsychotics, which generally followed the guidelines. There is insufficient evidence regarding the effects of the prescribed antidepressants and the risk of manic episodes, and further evidence needs to be collected.

Prescribing of low- versus high-cost Part B drugs in Medicare Advantage and traditional Medicare.

Examine whether Medicare Advantage (MA) coverage is associated with more efficient prescribing of Part B drugs than traditional Medicare (TM) coverage. Twenty percent sample of 2016 outpatient and carrier TM claims and MA encounter records and Master Beneficiary Summary File data. We analyzed whether MA enrollees compared to TM enrollees more often received the low-cost Part B drug in four clinical scenarios where multiple similarly effective drugs exist: (1) anti-VEGF agents to treat macular degeneration, (2) bone resorption inhibitors for osteoporosis, (3) bone resorption inhibitors for malignant neoplasms, and (4) intravenous iron for iron deficiency anemia. We then estimated differences in spending if TM prescribing aligned with MA prescribing. Finally, using linear probability models, we examined whether differences in MA and TM prescribing patterns were attributable to differences in the hospitals and clinician practices who treat MA and TM enrollees or differences in how these hospitals and clinician practices treat their MA versus TM patients. Not applicable. In all cases, a larger share of MA enrollees received the low-cost drug compared to TM enrollees, ranging from 8 percentage points higher for anemia to 16 percentage points higher for macular degeneration in the unadjusted analysis. Results were similar in regression analyses controlling for enrollee characteristics and market factors (5-13 percentage points). If TM prescribing matched MA prescribing, we estimated savings ranging from 6% to 20% of TM spending for each scenario. Differences in prescribing patterns were driven both by MA enrollees receiving treatment at more efficient hospitals and clinician practices and hospitals and clinician practices more often prescribing low-cost drugs to their MA patients. Our findings show MA enrollees were more likely than TM enrollees to receive low-cost Part B drugs in four clinical scenarios where multiple similarly or equally effective treatment options exist.

Epidemiology of trigeminal neuralgia: an electronic population health data study in Korea.

BackgroundTrigeminal neuralgia (TN) is one of the most painful disorder in the orofacial region, and many patients have suffered from this disease. For the effective management of TN, fundamental epidemiologic data related to the target population group are essential. Thus, this study was performed to clarify the epidemiological characteristics of TN in the Korean population. This is the first national study to investigate the prevalence of TN in Korean patients.MethodsFrom 2014 to 2018, population-based medical data for 51,276,314 subscribers to the National Health Insurance Service of Korea were used for this study.ResultsThe incidence of TN was 100.21 per 100,000 person-years in the year of 2018 in Korea, and the male to female ratio was 12.14. The age group of 51-59 years had the highest prevalence of TN. Constant increases in medical cost, regional imbalance, and differences in prescription patterns by the medical specialties were showed in the management of TN.ConclusionsThe results in this study will not only help to study the characteristics of TN, but also serve as an important basis for the effective management of TN in Korea.

Validating a model for medication-related dental outcomes in older people.

To externally validate a model for medication-related dental outcomes in (a) a general older population with dementia and (b) a matched population without dementia. This validation study used population-based data from seven Swedish national registers (2008-2017). Individuals aged 60+ with dementia were matched to those without dementia on age, gender, and county of residence at the date of diagnosis (index date). The exposure was continuous use of xerogenic medications during the 3-year period before index date. The primary outcome was the number of tooth extraction and restorative procedures within 3years after index date. A total of 334,220 individuals were included in the final sample. In the dementia cohort, the use of urological drugs (incidence rate ratio [IRR] 1.08, 95% CI 1.03-1.13), respiratory medicines (IRR 1.10, 95% CI 1.04-1.17), and proton-pump inhibitors (IRR 1.09, 95% CI 1.05-1.13) was associated with the primary outcome. In the non-dementia cohort, respiratory medicines (IRR 1.03, CI 1.00-1.05), proton-pump inhibitors (IRR 1.06, CI 1.04-1.08), opioids (IRR 1.05, CI 1.03-1.07), and antidepressants (IRR 1.06, CI 1.04-1.08) were associated with the primary outcome. Although there were differences in prescription patterns, the model performed similarly in both those with and without dementia.

Polish regional differences in patient knowledge on atrial fibrillation and its management as well as in patterns of oral anticoagulant prescription.

BACKGROUND The Jessa Atrial Fibrillation Knowledge Questionnaire (JAKQ) was successfully used to assess knowledge gaps in patients with atrial fibrillation (AF). AIMS To evaluate the regional differences among Polish patients in their awareness of AF diagnosis and oral anticoagulation use. METHODS A total of 1583 patients with AF at a median (IQR) age of 72 (66-79) years completed the JAKQ in 3 cardiology centers (center I, Kraków; center II, Toruń; center III, Kielce) from January 2017 to June 2018. The final analysis included 1525 patients, 32.9% were on vitamin K antagonists (VKAs) and 67.1% on non-VKA oral anticoagulants (NOACs), that is, rivaroxaban and dabigatran (28.9% each), and apixaban (9.3%). RESULTS The mean (SD) score on the JAKQ was 55.5% (18.4%) with better results among patients on VKAs compared with NOACs (58% [18.3%] vs 54.3% [18.4%]; P = 0.0002) with time from AF diagnosis more than 12 months (57.4% [17.5%] vs 50% [19.9%]; P <0.0001). There was a significant difference in the knowledge scores between the 3 centers (I, 59.5%; II, 48.5%; III, 54.3%; P <0.0001). In all centers the number of correct answers correlated inversely with patient's age (r = -0.20; P <0.0001). NOACs were more frequently used in center III. The percentage of correct responses was lower in patients on reduced NOAC doses (35.4% of patients on NOACs), compared with the full-dose NOAC groups in center I (56.9% vs 62.5%; P = 0.012) and II (48.1% vs 56.2%; P = 0.003). CONCLUSIONS Patients from a high-volume academic center showed better knowledge than their peers from district hospitals. There are large regional differences in prescription patterns of oral anticoagulants, including the preferred NOAC.

Abstract 17373: Prescription Patterns and Outcomes of Direct Oral Anticoagulants and Warfarin in Patients With Atrial Fibrillation a Real World Analysis

Introduction: Direct Oral Anticoagulants (DOACs) are used for stroke prevention in Atrial Fibrillation (AF). Hypothesis: We sought to evaluate differences in prescription patterns of DOACs and warfarin in new onset AF patients in relation to CHA2DS2Vasc score and compare outcomes of ischemic stroke, gastrointestinal (GI) bleed and intracranial hemorrhage (ICH) between DOACs and warfarin. Methods: All patients with a new diagnosis of AF from 2014 to 2017 were identified from the admission database at the University of Arkansas for Medical Sciences, AR, U.S.A. Trends in anticoagulant prescription were plotted in relation to CHA2DS2Vasc score. Baseline characteristics were compared using t-test and chi-square test as appropriate. Multivariate logistic regression was used to identify independent predictors of clinical outcomes of interest. Results: We examined a total of 2362 patients (1306 on warfarin and 1056 on DOACs). Prescription rates of warfarin increased with increasing CHA2DS2Vasc (Fig 1). Patients on warfarin had a higher prevalence of hypertension, diabetes, heart failure, renal failure and liver disease (Table 1a). On multivariate analysis, there was no difference in the incidence of ischemic stroke and GI bleeding between warfarin and DOACs (Table 1b). However, there was a trend towards lower incidence of ICH in DOAC group (p=0.06), despite wider usage in patients with higher CHA2DS2Vasc score. Conclusions: In a real-world setting, the use of DOACs was lower in patients with high CHA2DS2Vasc score compared with warfarin. Trend towards lower incidence of ICH was present in DOAC group. Further larger studies assessing safety of DOACs in patients with high CHA2DS2Vasc are needed.

Differences in Pediatric Headache Prescription Patterns by Diagnosis.

Few studies have reported prescription patterns for headache medication. The aim was to present the rates of specific medication prescribed to pediatric patients diagnosed with migraine, tension-type headache (TTH), and new daily persistent headache (NDPH), as well as differences in those prescription patterns by diagnosis, age, and gender. A query using the i2b2 platform yielded 14,591 patients [migraine 10,547 (72.3%); TTH 3200 (21.9%); NDPH 844 (5.8%)] seen over a 3-year period, who were aged 4-17years at the time of their visit and diagnosed with migraine, TTH, or NDPH. Sumatriptan was the most frequently prescribed medication for migraine followed by amitriptyline. The most frequently prescribed medication for both TTH and NDPH was amitriptyline, followed by sumatriptan in TTH and by topiramate in NDPH. Age and gender differences were also found in prescription patterns of each of the diagnoses. The differences in prescription patterns found between the diagnoses, as well as age and gender differences found within the diagnoses, are discussed. A wide range of medications are prescribed to children and adolescents with headache, with most medications prescribed for off-label use. As these medications are not Food and Drug Administration (FDA) approved for use in children and adolescents with headache, there is a need for large scale, randomized controlled trials to assess the efficacy of these medications.

Correlation of Opioid Mortality with Prescriptions and Social Determinants: A Cross-sectional Study of Medicare Enrollees.

The opioid epidemic is an escalating health crisis. We evaluated the impact of opioid prescription rates and socioeconomic determinants on opioid mortality rates, and identified potential differences in prescription patterns by categories of practitioners. We combined the 2013 and 2014 Medicare Part D data and quantified the opioid prescription rate in a county level cross-sectional study with data from 2710 counties, 468,614 unique prescribers and 46,665,037 beneficiaries. We used the CDC WONDER database to obtain opioid-related mortality data. Socioeconomic characteristics for each county were acquired from the US Census Bureau. The average national opioid prescription rate was 3.86 claims per beneficiary that received a prescription for opioids (95% CI 3.86-3.86). At a county level, overall opioid prescription rates (p<0.001, Coeff=0.27) and especially those provided by emergency medicine (p<0.001, Coeff=0.21), family medicine physicians (p=0.11, Coeff=0.008), internal medicine (p=0.018, Coeff=0.1) and physician assistants (p=0.021, Coeff=0.08) were associated with opioid-related mortality. Demographic factors, such as proportion of white (p white<0.001, Coeff=0.22), black (p black<0.001, Coeff=-0.19) and male population (p male<0.001, Coeff=0.13) were associated with opioid prescription rates, while poverty (p<0.001, Coeff=0.41) and proportion of white population (p white<0.001, Coeff=0.27) were risk factors for opioid-related mortality (p model<0.001, R 2=0.35). Notably, the impact of prescribers in the upper quartile was associated with opioid mortality (p<0.001, Coeff=0.14) and was twice that of the remaining 75% of prescribers together (p<0.001, Coeff=0.07) (p model=0.03, R 2=0.03). The prescription opioid rate, and especially that by certain categories of prescribers, correlated with opioid-related mortality. Interventions should prioritize providers that have a disproportionate impact and those that care for populations with socioeconomic factors that place them at higher risk.

Variation in post-discharge opioid prescriptions among members of a surgical team

BackgroundSurgeons play a pivotal role in the opioid epidemic but it is unknown how different members of a surgical team vary in the way they prescribe opioids after surgical episodes. Study designWe conducted a retrospective cohort study of all inpatient discharges for 5 common surgeries. Total number of tablets and total milligram equivalents (MME) prescribed were calculated and differences in prescription patterns were determined for attending surgeons, surgical residents and advanced practice providers. Using a generalized ordered logistic regression, we examined factors associated with ordering a higher number of tablets or MME. ResultsThe median number of tablets (range) prescribed by rank were attending surgeon 30 (6–72), surgical resident 20 (6–189) and advanced care practitioner 40 (5–1000); p < 0.001.The median total MME prescribed by rank were attending surgeon 140 (30–600), surgical resident 200 (30–1600) and advanced practice provider 240 (25–1000); p < 0.001. There was no statistically significant difference by resident postgraduate year (PGY) for both total tablets and total MME prescribed. General surgery residents on average ordered a narrower range of total MME compared to surgical residents in other surgical specialties [20 (50–600) vs 20 (30–1600); p = 0.03]. On regression analysis, residents were less likely to order a higher number of tablets compared to attending surgeons (OR 0.29, p = 0.01). However, surgical residents and advanced care providers were more likely to prescribe a higher total MME compared to attending surgeons (OR 7.12, p < 0.001; OR 3.39, p = 0.01 for surgical resident and OR 6.46, p = 0.01) for advanced practice providers). ConclusionThere is wide variation in opioid prescription patterns by surgical providers. More studies are needed to clearly define the ideal number of tablets or MMEs to prescribe for common surgical procedures.

Prescription Patterns and Disease Control in Type 2 Diabetes Mellitus Patients in Nursing Home and Home Care Settings: A Retrospective Analysis in Germany.

The aim of this study was to analyze prescription patterns and disease control in patients with type 2 diabetes mellitus (T2DM) in nursing home and home care settings in Germany. The present study is based on data from the Disease Analyzer database (QuintilesIMS). Patients with an initial diagnosis of T2DM and documented HbA1c values between January 2011 and December 2015 were included in the analysis. The index date corresponded to the last documented HbA1c value. Patients in nursing homes were matched (1:1) with patients living at home based on age, gender, and dementia diagnosis. The first outcome of the study was the share of use of several antidiabetic drugs in the two different settings. The second outcome was the mean HbA1c value and the proportion of patients with HbA1c values lower than 7% in the two different groups. In this study, 4925 individuals lived in nursing homes and 4925 individuals lived at home. The mean age was 80.7 years (SD = 7.7). Prescription patterns differed significantly between nursing home and home care settings: insulin (57.9% vs 41.1%), metformin (46.6% vs 60.5%), sulfonylurea (24.9% vs 34.2%), DPP4 inhibitors (13.4% vs 19.8%), and other antihyperglycemic drugs (7.8% vs 12.1%). In contrast, mean HbA1c values (nursing home: 7.2%; home: 7.2%) and the share of patients with Hb1Ac values lower than 7% (nursing home: 49.1%; home: 50.9%) did not differ significantly between the two groups. Overall, the differences in prescription patterns between nursing homes and home care were not associated with significant differences in the management of T2DM.

Trends in Antiepileptic Drug Prescriptions for Childhood Epilepsy at a Tertiary Children's Hospital in Korea, 2001-2012.

Longitudinal prescription patterns of antiepileptic drugs (AEDs) have not been described to date in Korea. Here we aimed to describe AED prescribing trends over a 12-year period and assess age differences in AED prescribing patterns in a pediatric epilepsy population. We retrieved and analyzed all AED prescribing and dispensing data in 2001-2012 in patients aged 0-18 years with an established diagnosis of epilepsy at the largest tertiary children's hospital in Korea. AEDs included for analysis were classified as older (i.e., carbamazepine, ethosuximide, phenobarbital, phenytoin, and valproic acid) and newer (i.e., gabapentin, lamotrigine, levetiracetam, oxcarbazepine, pregabalin, topiramate, vigabatrin, zonisamide, lacosamide, and rufinamide) on the basis of market availability before versus after 1991. A total of 5593 patients with epilepsy were prescribed an AED during the 12-year period. The proportion of newer AED prescriptions was 52.6 % in 2001 and continuously increased to 74.3 % in 2012. Oxcarbazepine was most widely used, followed by valproic acid. While carbamazepine and vigabatrin use progressively decreased over the 12-year period, those of lamotrigine and topiramate rapidly increased. Age differences in prescribing patterns were observed. Polytherapy was observed in 49.7 % of the total population, while 83.9 % of new users were prescribed monotherapy. This study provided updated information on AED prescription trends for childhood epilepsy. We found a progressive increase in the use of newer AEDs. However, valproic acid, the only prevalent older AED, continued to be widely prescribed. A high rate of polytherapy among the prescriptions overall raises some safety concerns.

Clinical preference for factors in treatment of geriatric depression.

Little is known about symptom preferences of clinical psychiatrists in the treatment of geriatric depression and preferences for avoiding adverse drug effects. Participants (board-certified psychiatrists) were recruited prior to a lecture on geriatric depression during a continuing education program. An analytic hierarchy process was performed and participants were asked for pairwise comparison of criteria guiding them in appraising therapeutic efficacy, and in avoiding toxicity and adverse events. Of the 61 participants from the continuing education program, 42 (69%) returned their data sheet. Avoidance of cardiotoxicity was regarded as more important than avoidance of hepatotoxicity or hematotoxicity. Concerning adverse events, highest preference was given to avoidance of falls and drug interactions, followed by avoidance of sedation, weight change, and impairment of sexual function. The most important preferences for appraisal of therapeutic efficacy were suicidality over ability to concentrate and sleep. Clinical psychiatrists have a hierarchy of preferences for treatment goals and avoidance of adverse events and toxicity. This raises the question for future research whether these preferences cause differences in prescription patterns in clinical practice even though a multitude of antidepressants are similarly effective when judged with instruments used in clinical trials.