Medication Dispensing Research Articles

Fundamental issues and pandemic pushes pharmacists past their limits

Fundamental issues and pandemic pushes pharmacists past their limits

The association of specific industry-related air pollution with occurrence of chronic diseases: A register-based study

Air pollution may contribute to onset and progression of chronic diseases such as cardiovascular and respiratory diseases. Most studies have focused on the contribution of traffic-related exposure to PM10 or PM2.5. Our aim was to investigate the association of different components of industry-related air pollution on the occurrence of chronic diseases.A register-based repeated cross-sectional study was conducted among 89,714 subjects (2012) with 536,599 annual observations (2012–2017) living in the vicinity of a large industrial area in the Netherlands. Information from the dispensed medication registration was linked with a dispersion model to characterize annual individual-level exposure of all subjects at place of residence. Associations between annual exposure (concentration and duration) to particulate matter (PM10), nitrogen oxides (NOX), sulphur dioxide (SO2), and volatile organic compounds (VOC) with annual dispensed medication for cardiovascular diseases, respiratory diseases, diabetes mellitus, and inflammatory conditions were investigated by multivariate logistic regression analysis with generalized estimating equations (GEE) while controlling for confounders.Exposure to PM10 and to NOX (per μg/m3) were significantly associated with medication for cardiovascular diseases (OR 1.06, 95CI% 1.06–1.06 and OR 1.01, 95%CI 1.01–1.01 respectively). Exposures to PM10 and SO2 (per μg/m3) were significantly associated with medication for inflammatory conditions (OR 1.05, 95%CI 1.00–1.09 and OR 1.07, 95%CI 1.01–1.14 respectively). Exposure to SO2 was inversely associated with respiratory diseases (OR 0.91, 95%CI 0.86–0.97). Except for inflammatory conditions, exposure duration (years) was significantly associated with the other three chronic diseases (OR varying from 1.01 to 1.03).This study indicates that specific air pollution components caused by industry may contribute to the occurrence of cardiovascular diseases, respiratory diseases, diabetes mellitus, and inflammatory conditions.

General practitioners treating their own family members: a cross-sectional survey in Germany

BackgroundIn Germany, there are neither guidelines provided by the medical associations nor a public discussion about general practitioners (GPs) treating their family members. Only few studies on this topic from the primary care setting exist. The aim of this study is to describe GPs’ treatment of family members and to generate empirical data on the most common reasons for this.MethodsIn June 2018 we conducted a postal survey among GPs in the North Rhine region of Germany. The questionnaire was developed in a stepwise process including initial expert panels, interviews with GPs, item construction workshops, cognitive pre-tests and pilot testing with 40 questionnaires. The final questionnaire addressed: type and frequency of treatment, documentation and place of treatment, engagement as the official GP as well as reasons for and against the treatment. For data evaluation, descriptive and explorative statistical analyses were conducted.ResultsOverall, 393 questionnaires were returned (response rate 39.8%). 96.7% of the GPs had treated at least one family member during the last 12 months. Services that were provided frequently (more than three times in the last 12 months) included the prescription or dispensing of medication (partner 45%, children 37%, parents 43%, partner’s parents 26%), physical examinations (partner 18%, children 24%, parents 25%, partner’s parents 15%), and the arrangement or provision of laboratory tests (partner 14%, children 7%, parents 16%, partner’s parents 9%). Less than one third of the study participants always treated their relatives in their office. Male GPs more often provided care to family members (except children) registered in their practice. Senior male GPs treated their relatives more often than junior female GPs. Family members were most commonly treated for practical reasons.ConclusionThe subject of GPs treating their relatives is of high everyday relevance, since nearly all GPs are involved in the treatment of their family members. Frequent at-home treatments and low documentation rates may indicate risks due to deviating from the professional routine.

Incidence of complications of herpes zoster in individuals on immunosuppressive therapy: A register-based population study

ObjectivesHerpes zoster (HZ) exposes to alterations of the quality-of-life. HZ is more frequent in immunocompromised individuals, but whether immunosuppression is associated with a higher rate of complications is not well documented. We aimed to assess association between drug-induced immunosuppression and HZ complications. MethodsData from a sample of the French healthcare claims from 01/01/2006 to 12/31/2018 were analyzed. Complicated zoster (CZ) was defined as a hospitalization with a code for HZ or the first-time dispensation of high-dose valacyclovir and specific neuralgia analgesics. Drug-induced immunosuppression was identified through medication dispensation. Risk ratios were calculated to compare incidences in exposed individuals (EI) and non-exposed to immunosuppressive therapy (NEI). ResultsWe identified 227 and 2838 CZ, accounting for an incidence of 178 per 100,000 person-year (95%CI[154.9–201.1]) and 51.7 per 100,000 person-year (95%CI[49.8–53.6]), in EI and NEI, respectively (risk ratio: 3.44 (95%CI[3.01–3.94]). Mean age was 66 years in both groups. CZ occurred after a median of 11.7 months (IQR[5.3–49.9]) of immunosuppressive therapy. Post-herpetic neuralgia (PHN) lasted at least 3 months in 32.6% and 22.5% of cases in EI and NEI, respectively (p=.01). ConclusionsDrug-induced immunosuppression increases the risk of CZ and exposes to longer-lasting PHN. Figures provided in this study could help guide prophylaxis of HZ.

Implementing computerized physician order entry in a public tertiary care hospital.

It is reported that at least one medication error per day occurs in hospitalized patients. Medication errors are not only harmful but also expensive. Prescription review by pharmacists is the standard to reduce prescribing error; however, due to the manual process, pharmacists lack time to conduct prescription reviews. Computerized physician order entry (CPOE) allows clinicians to directly place medication orders electronically, transmitted directly to the pharmacy. Successfully implemented CPOE systems improve the prescribing process and result in fewer medication errors. However, regardless of its significance, implementation of CPOE is a very difficult task, particularly in a public-sector hospital. Lady Reading Hospital-Medical Teaching Institution has a manual system for indenting medication system; pharmacists could only ensure the current dispensing of medication, but lack time and information to conduct a review to ensure the appropriateness of prescription. The article entails the barriers and the process of implementation of e-prescribing.

Evaluation of pharmacy students’ knowledge and perceptions of transitions of care services

Introduction: Studies support incorporation of pharmacists and pharmacy students to improve health and financial outcomes during transition of care (TOC). Standardisation of TOC educational training is currently lacking in pharmacy curricula. Methods: This study employed a cross-sectional, descriptive study with a convenience sample at one college of pharmacy. Students participated in an anonymous Qualtrics survey including items on TOC service understanding and educational training. Results are reported as means and standard deviation for continuous data; frequencies and percentages for categorical data. Results: Of 116 survey responses, 112 provided informed consent. Seventy-eight percent of respondents stated they have learned about TOC and 66% felt they understood what TOC entails. When asked to identify disease states commonly targeted for TOC, 77% responded incorrectly to this item. When asked to select TOC clinical activities, 66% incorrectly selected medication dispensing. Ninety-six percent of respondents replied that additional educational training on TOC would be beneficial. Conclusion: There is a discrepancy in students’ perception of TOC services with their actual knowledge of TOC services based on survey responses.

The Journey to Advanced Clinical Pharmacy Practice: Global Collaboration Will Accelerate the Pace

The Journey to Advanced Clinical Pharmacy Practice: Global Collaboration Will Accelerate the Pace

The effect of a methadone reformulation on opioid agonist treatment outcomes: A population-based study in British Columbia, Canada, 2013–14

IntroductionThe province of British Columbia, Canada, changed the existing oral anhydrous methadone solution to a 10-times more concentrated pre-mixed solution, Methadose®, on February 1, 2014. We aimed to assess the immediate effects of the methadone reformulation on missed doses, days off methadone, changes in medication dosing and dispensations of opioids for pain, and hospitalizations and mortality among all people receiving treatment at or near the time of the change. MethodsWe conducted a population-based retrospective cohort study including all individuals receiving at least one methadone dispensation in the 12 months prior to the study period. We executed a difference-in-differences analysis by estimating a multivariate regression model to compare outcomes in the three months before and after the reformulation (November 1, 2013 to April 30, 2014) versus a time-lagged control cohort with similar characteristics observed during an equivalent nonoverlapping interval. We used daily individual-level linked health administrative data capturing missed doses, days off methadone, changes in methadone dosing, concurrent dispensations of opioids for pain, hospitalizations, and mortality. We stratified the cohorts into three subgroups: (i) those receiving OAT for ≥12 months; (ii) those receiving OAT for <12 months; and (iii) those not receiving OAT at the start of the study period. We conducted sensitivity analyses and placebo tests to assess the robustness of our results. ResultsAmong the 16,339 individuals receiving methadone during the study period, the reformulation was associated with more instances of methadone dose increases (34.5% [95% Confidence Interval (CI): 27.4%, 41.5%]). For those retained in treatment ≥12 months prior to the study period (n = 7449), the reformulation was associated with more instances of methadone dose increases (50.2% [39.5%, 60.8%]) and dispensations of opioids for pain (62.2% [40.8%, 83.5%]), as well as an increase in missed doses (41.9% [29.1%, 54.7%]) and days off methadone (62.6% [39.7%, 85.4%]). We found no statistically significant change in risk of hospitalization or mortality. Sensitivity analyses supported our results. ConclusionOur results reinforce the need expressed by people receiving methadone for greater client involvement in the planning and implementation of regulatory changes that may impact client care, especially those patients with a relatively long treatment history.

Automated Dispensing Cabinet Functionality Expansion to Reduce Controlled Substance Inventory Discrepancies.

Automated dispensing cabinets have the potential to create technology-induced errors that can arise during controlled substance medication dispensing. Despite enhancements made to the medication use process, the impact of ADC functionality on technology-induced controlled substance discrepancies have yet to be described. To evaluate the impact of ADC functionality expansion on technology-induced errors such as controlled substance discrepancies created during "blind inventory counts" and cassette dispensing errors. This quasi-experimental study was conducted over 18 months that evaluated the expanded use of dispensing cassettes within 8 ADCs at the University of Chicago Medicine. Unit-dose controlled substances with high usage were directed for inventory reassignment to cassettes. Controlled substance dispenses, blind inventory counts discrepancies and cassette dispensing errors were evaluated before and after cassette expansion. ADC discrepancy and Cassette Dispensing Error rates were calculated using 1-week segments across the study period. Of the 64 040 dispenses during the study period, the proportion of cassette dispenses increased from 16% to 72% after cassette expansion. Controlled substance discrepancies decreased from 11 to 7 discrepancies for every 1000 dispenses (P < .0001). After cassette expansion, cassette dispensing errors increased to roughly 28 errors for every 1000 dispenses (P < .0001). Expansion of ADC functionality created opportunities for reduced technology-induced controlled substance discrepancy rates at the expense of increased cassette dispensing errors.

555. Utilization of Remdesivir for COVID-19 in the National Veterans Affairs Healthcare System

BackgroundAs remdesivir (GS-5734) has become a leading treatment for COVID-19, we sought to assess remdesivir utilization patterns, including utilization of concomitant and supportive therapies, and heterogeneity in treatment approaches.MethodsOur retrospective cohort study included hospitalized Veterans with positive COVID-19 PCR tests treated with remdesivir, from 03/2020 through 4/2021. Using exposure mapping of barcode medication administration records and medication dispensings, we assessed other medications received by each patient on each day of remdesivir treatment. Heterogeneity was defined as patterns of treatment (drug & duration) not shared by any other patient.ResultsOur study included 13,665 patients with COVID-19 receiving remdesivir. The median time to remdesivir initiation from either positive test or hospital admission was 1 day (interquartile range [IQR] 0-4 and 0-1, respectively). The median duration of remdesivir treatment was 5 days (IQR 4-5 days). Median length of hospital stay was 7 days (IQR 4-13). Inpatient mortality was 13.9% and an additional 6.2% of patients died within 90 days of discharge. The most common concomitant and supportive therapies were anticoagulants/antiplatelets (94.8%; enoxaparin 72.6%, heparin 18.4%, apixaban 10.8%, clopidogrel 6.3%), corticosteroids (90.8%; dexamethasone 87.3%, prednisone 2.9%, methylprednisolone 5.5%), statins (55.8%; atorvastatin 38.2%, simvastatin 7.1%, rosuvastatin 6.0%), antibiotics (41.9%; azithromycin 25.6%, ceftriaxone 13.2%, doxycycline 6.0%, vancomycin 4.9%), angiotensin receptor blockers (11.9%) and angiotensin-converting enzyme inhibitors (20.4%), melatonin (29.7%), and aspirin (35.6%). Concomitant utilization of Janus kinase inhibitors (0.5%), interleukin-6 inhibitors (2.4%), and hydroxychloroquine (0.5%) was low. Heterogeneity in concomitant and supportive therapies during remdesivir treatment was 84.6% (68.3% when assessed as drug class/category). ConclusionAmong hospitalized patients with COVID-19 in the national VA Healthcare system receiving remdesivir, remdesivir was initiated early in the admission and substantial heterogeneity was observed in concomitant and supportive therapies during remdesivir treatment.Disclosures Aisling Caffrey, PhD, Merck (Research Grant or Support)Pfizer (Research Grant or Support)Shionogi, Inc (Research Grant or Support)

809. Evaluation of Antimicrobial Prophylaxis Prescribing in Post-operative Neurosurgical Procedures

BackgroundDue to lack of relevant clinical data or guidelines, duration of post-operative prophylactic antimicrobial therapy for neurosurgical procedures at the Kaiser Permanente Northern California (KPNC) hospitals has varied among patients and is largely based on the clinical judgment of surgeons. Non-standardized perioperative microbial prophylaxis practice has been associated with excessive antimicrobial therapy, increased risk of drug resistance, institutional cost, and adverse drug effects. This study aims to evaluate differences in prescribing practices of post-operative prophylactic antibiotics among neurosurgeons and to observe the incidence of surgical site infections and adverse drug events caused by antimicrobial prophylaxis that are associated with varying durations of post-procedure prophylaxis.MethodsA retrospective, observational study of health plan members of KPNC who underwent neurosurgical procedures from 01/01/2011 to 12/31/2019. Prophylactic antimicrobial therapy and duration was identified from medication dispensing and administration records. The study analyzed rates of surgical site infection, post-surgical wound drainage, 60-day mortality, and adverse drug events within 60 days of surgery.ResultsThe cohort consisted of 491 patients. 140 received antibiotics for >24 hours and 351 received antibiotics for ≤24 hours. The most common procedures analyzed in our patient population were VP shunt insertion (70.7%) and craniotomy subdural hematoma evacuation (17.9%). There were more surgical site infections in those who received antibiotics >24 hours (4.3% vs 1.4%, p value= 0.05). Univariate logistic regression model showed receiving antibiotics for ≤ 24 hours significantly decreased chance of composite drug event (odds ratio 0.345, 95% CI 0.172-0.691, p value= 0.003).ConclusionThis study demonstrated that antimicrobial prophylaxis for neurosurgical procedures ≤24 hours decreases risk of adverse drug events. The study provides further evidence to support the development of a standardized protocol that recommends short duration of antibiotic prophylaxis for neurosurgical procedures at KPNC.Poster Disclosures All Authors: No reported disclosures

Impact of the COVID-19 pandemic: Community and hospital shared pharmaceutical care model. Satisfaction and acceptability of patients with HIV infection on antiretroviral treatment.

BackgroundThe health crisis due to the COVID-19 pandemic is a challenge in the dispensing of outpatient hospital medication (OHM). Models of Antiretroviral Therapy (ART) based on community pharmacy support (ARTCP) have proven to be successful. The aim was to evaluate the degree of satisfaction, acceptability and limitations of the implementation of ARTCP, in the context of a pandemic, in our environment.MethodsDescriptive cross-sectional study carried out in a Barcelona hospital, during the months of July-November 2020. A telephone survey was carried out via a questionnaire on the quality dimensions of the model (degree of satisfaction, acceptability) and associated inconveniences. Data collected: demographics, antiretroviral treatment (ART), concomitant medication, drug interactions (DDIs), CD4 lymphocyte count and plasma viraemia. Data analysis included descriptive statistics.ResultsA total of 533 (78.0%) HIV patients receiving ART were included. 71.9% (383/533) of these patients were very satisfied and 76.2% preferred attending the community pharmacy rather than the hospital. The mean satisfaction rating was 9.3 (DS: 1.4). The benefits reported were: 1) proximity to home (406: 76.1%); 2) lower risk of contagion of COVID-19 (318: 59.7%); 3) shorter waiting time (201: 37.1%); 4) time flexibility (104: 19.5%); 5) reduction of financial expenses (35: 6.57%). A total of 11 (2%) patients reported no benefit. Only 22.9% reported disadvantages associated with ARTCP: 1) lack of privacy (65: 12.2%); 2) lack of coordination-organization (57: 10.7%).ConclusionThe COVID-19 pandemic has had an impact on the provision of pharmaceutical care for HIV patients. The ARTPC model has proved efficient, with patients reporting a high degree of satisfaction.

The relationship of socioeconomic factors to the use of preventative cardiovascular disease medications: A prospective Australian cohort study

Cardiovascular disease (CVD) events are highly preventable through appropriate treatment and disproportionally affect socioeconomically disadvantaged individuals. This study quantified the relationship of socioeconomic factors to dispensing and persistent use of lipid- and blood pressure-lowering medication following hospital admission for a major CVD event (myocardial infarction, ischaemic stroke/transient ischaemic attack). Data from 8285 people with such events aged ≥45 years from the Australian 45 and Up Study with linked medication data were used to estimate relative risks (RRs) for combined lipid- and blood pressure-lowering dispensing at three-months following hospital discharge and for 12-month persistent use, in relation to education, income, and level of medication subsidisation. Overall, 56% were dispensed guideline-recommended medications at three months and 37% persistently used them across 12 months. After adjusting for demographic factors, type of CVD and history of CVD hospitalisation, RRs for lowest (no educational qualifications) compared to highest education level (university degree) were 1.14 (95% CI: 1.06, 1.22) for medication dispensing and 1.15 (1.02, 1.29) for persistent medication use; 1.14 (1.06, 1.22) and 1.17 (1.04, 1.32) respectively for lowest (<$20,000) versus highest (≥$70,000) household pre-tax income; and 1.25 (1.17, 1.33) and 1.28 (1.15, 1.43) respectively for those receiving highest versus lowest subsidisation. There was little to no evidence of a relationship of income and education to medication use after adjustment for medication subsidisation. While preventive medication use is sub-optimal, subsidisation is substantially associated with increased use and accounts for most of the relationship with socioeconomic position, suggesting subsidy schemes are working in the intended direction.

Medicines Delivery Proximity Programme (PEMProxi) survey results

ObjectivesTo evaluate patients’ and community pharmacies’ satisfaction towards the Medicines Delivery Proximity Programme (PEMProxi), including patients’ level of satisfaction with pharmaceutical services, medication dispensing and delivery, cost, and time saved,...

Assessment of Community Pharmacist's Practice and Patient Counselling Toward Acute Diarrhea Treatment in Khartoum Locality: A Simulated Patient Study.

BackgroundAcute diarrhea is one of the most common health problems globally as a minor ailment, it is widely managed by community pharmacists (CPs). Professional patient counseling provided in community pharmacies is essential to decide about acute diarrhea and avoid treatment failure properly.ObjectiveTo assess CPs’ history-taking practice, medication dispensing, and patient counseling in response to acute diarrhea in adults.MethodsA cross-sectional, covert simulated patient (SP) study was conducted in 235 community pharmacies in the Khartoum locality. Two scenarios were used, one scenario assesses afterwards compliance to treatment guidelines and patient counseling, and second scenario determines afterwards if pharmacists referred patients to medical consultation. Six final-year pharmacy students were involved as SPs. All encounters were audio-recorded by SP. Then the investigator filled the checklist that was intended to evaluate the overall practice of pharmacists.ResultsAs planned, 235 pharmacies were visited twice, resulting in a total of 470 visits (visit completion rate: 100%). In history taking, the most asked questions were the patient’s age (89.8% for scenario 1 and 88.5% for scenario 2). Followed by the presence of blood in the stool (25.5% for scenario 1 and 28.1% for scenario 2). In scenario 1, loperamide was the most dispensed medication (81.3%), while oral rehydration solution (ORS) was dispensed in 0.9% of the visits. In counseling, verbal and written instructions were provided in 47.7% of the visits. Duration of medications was mentioned in 3.8%, advice about fluid intake was offered in 7.2% of the visits. In scenario 2, 17% of the pharmacists managed patient history well to refer patients to medical consultation, while 42.6% recommended referral after sufficient information was provided by the SP.ConclusionCPs’ practice in counseling toward acute diarrhea was poor; referral to medical consultation was below expectation. The current CPs dispensing practices need improvement; thus, professional education should be encouraged.

P.035 Health System Utilization and Medication Use among Adults with Migraine in Alberta: An observational cohort study using Alberta administrative health data

Background: Migraine is costly to governments. Despite significant burden, Canada lacks population data regarding migraine prevalence, resource and medication utilization. We sought to characterize the demographics, health resource utilization, and medication use in an adult migraine cohort in Alberta. Methods: Migraine cohort: previously validated case definition of migraine (ICD 10 + dispensation of abortive and/or preventative migraine drug (04/2010-03/2016). Patients over 18 years, followed three years from index date [first dispensation of migraine medication]. Health resource utilization (HRU) assessed by emergency department (ED) visits, hospital admission and physician claims. Medication assessed province-wide dispensation database linkage. Patient demographics and Charlson Comorbidity Index (CCI) included. Results: Over 5 years: 53,333 migraine cases identified (mean age 40.5 years, 79% female). Common comorbidities: hypertension, COPD, diabetes mellitus, cancer, cerebrovascular disease. Mean CCI 0.55 (SD 1.06). Metropolitan patients: 48%, urban 34.6%, rural 17.4%. Initial migraine diagnosis: 46% by GP, 31% in ED. Rural patients present more to ED/hospital for care in 3-year follow-up (IRR 2.95 [2.83, 3.08]). Conclusions: Our migraine case definition is more specific than sensitive and underestimates Alberta’s migraine prevalence. Higher female prevalence as expected. Rurally, migraine care largely occurs in ED/hospital. Study of prevalence, HRU and medications may help inform health policy in Alberta and Canada.

Ensuring buprenorphine access in rural community pharmacies to prevent overdoses

BackgroundOpioid-related drug overdoses have been rapidly increasing in the United States, especially in rural Southern and Appalachian regions. The use of buprenorphine-containing medications to treat opioid use disorder (OUD) is an evidence-based approach proven to reduce overdose death risks. Access to such treatment is uneven, with less access in parts of the United States where overdose rates are higher. Pharmacy dispensing of buprenorphine is a key component of access, yet barriers related to perceived and actual regulatory constraints, training gaps, stigma, and challenges to prescriber-pharmacist communication limit dispensing of this life-saving medication. ObjectivesThe objectives of this study were to explore the experiences of rural patients with OUD filling prescriptions for buprenorphine-containing medications at community pharmacies. Practice DescriptionRural community pharmacies, both commercial chain and independent, in 2 rural South-Central Appalachian counties where the local health departments prescribe buprenorphine-containing medications. Practice InnovationThe local county health departments each entered into dedicated dispensing arrangements with a local independent community pharmacy to ensure a stable supply of medication for their patients with OUD who were prescribed buprenorphine. Evaluation MethodsQualitative interviews (n =16) with patients prescribed buprenorphine from their county health department; county health department staff, local harm reduction program staff, and harm reduction program participants prescribed buprenorphine. Transcripts were analyzed using thematic analysis. ResultsParticipants reported problems with buprenorphine dispensing at rural community pharmacies, dispensing delays that resulted in experiencing withdrawal symptoms and hesitation to continue in treatment, high medication costs, and stigmatizing treatment by some pharmacists. Participants also reported that access improved after dedicated dispensing arrangements began. ConclusionAgreements between prescribing health departments and community pharmacies could increase access to buprenorphine, especially in rural areas.

Physician Perspectives on Codeine Accessibility, Patterns of Use, Misuse, and Dependence in Saudi Arabia

In Saudi Arabia, there are concerning rates of non-compliance with pharmaceutical regulations prohibiting the pharmacy dispensing of prescription-only medications without a physician prescription. This is the first study in the Middle East which examines physicians’ perceptions regarding misuse of codeine, listed as a narcotic, controlled, and prescription-only drug. The CODEMISUSED survey was adapted to the Saudi Arabian context and pilot tested, prior to cross-sectional administration to physicians in Riyadh, Jeddah, Abha, and Jazan (n = 105). Descriptive statistics (frequencies and percentage) present physician level of agreement, neutrality, and disagreement with statements regarding codeine prescribing, patient awareness and use, online and community pharmacy availability, and dependence. The study indicates concern by physicians regarding patient intentional use of codeine to enhance mood, misuse patterns, lack of awareness around habit-forming use and iatrogenic dependence, and sourcing via illegal dispensing. It underscores the imperatives to address pharmacy compliance with pharmaceutical regulatory controls, implement enhanced pharmacovigilance, and improve awareness around safe use.

Tuberculosis treatment within differentiated service delivery models in global HIV/TB programming.

IntroductionProviding more convenient and patient‐centred options for service delivery is a priority within global HIV programmes. These efforts improve patient satisfaction and retention and free up time for providers to focus on new HIV diagnoses or severe illness. Recently, the coronavirus disease 2019 (COVID‐19) pandemic precipitated expanded eligibility criteria for these differentiated service delivery (DSD) models to decongest clinics and protect patients and healthcare workers. This has resulted in dramatic scale‐up of DSD for antiretroviral therapy, cotrimoxazole and tuberculosis (TB) preventive treatment. While TB treatment among people living with HIV (PLHIV) has traditionally involved frequent, facility‐based management, TB treatment can also be adapted within DSD models. Such adaptations could include electronic tools to ensure appropriate clinical management, treatment support, adherence counselling and adverse event (AE) monitoring. In this commentary, we outline considerations for DSD of TB treatment among PLHIV, building on best practices from global DSD model implementation for HIV service delivery.DiscussionIn operationalizing TB treatment in DSD models, we consider the following: what activity is being done, when or how often it takes place, where it takes place, by whom and for whom. We discuss considerations for various programme elements including TB screening and diagnosis; medication dispensing; patient education, counselling and support; clinical management and monitoring; and reporting and recording. General approaches include multi‐month dispensing for TB medications during intensive and continuation phases of treatment and standardized virtual adherence and AE monitoring. Lastly, we provide operational examples of TB treatment delivery through DSD models, including a conceptual model and an early implementation experience from Zambia.ConclusionsCOVID‐19 has catalysed the rapid expansion of differentiated patient‐centred service delivery for PLHIV. Expanding DSD models to include TB treatment can capitalize on existing platforms, while providing high‐quality, routine treatment, follow‐up and patient education and empowerment.

Compulsory Community Treatment Orders in New Zealand and the provision of care: An examination of national databases and predictors of outcome.

BackgroundCompulsory Community Treatment Orders (CTOs) are contentious because they impose severe restrictions on individuals in community settings. The existing evidence for CTOs is constrained by ethical and methodological limitations and may not support usual clinical practise. This study examines the effectiveness of CTOs using routine data in the New Zealand context.MethodsMinistry of Health, New Zealand databases provided demographic, service use, and medication dispensing data for all individuals placed on a CTO between 2009 and 2018. We examined the effectiveness of CTOs through a comparison of psychiatric endpoints identified as useful in the literature according to CTO status. Further analyses examined the moderating influences of age, sex, ethnicity, and diagnosis on outcome.Findings14,726 patients were placed under a CTO over the 10 year period between 1 January 2009 and 31 December 2018. Patients on CTOs experienced a reduced frequency of admissions (rate ratio of 0∙94, 95% CI 0.93-0.95, p<0.01) reduced admission days (rate ratio 0∙97, 95% CI 0.97-0.98 p<0∙01), increased frequency of psychiatric community contacts (rate ratio 3∙03, 95% CI 3.02-3.03 p<0.01), and increased dispensing of psychiatric medication (rate ratio 2.27, 95% CI 2.27-2.28, p<0.01). When sub-group analyses were undertaken, the association between treatment under a CTO and reduced admission frequency was only present for those with Psychotic Disorders.InterpretationCTOs in New Zealand are associated with increased community care, and increased dispensing of psychiatric medication. Patients with Psychotic Disorders also experienced reduced frequency and length of admissions whilst under a CTO.FundingNo specific funding was received for this study.