Greater Number Of Prescriptions Research Articles

Impact of functional disability on health-care use and medical costs among cancer survivors.

Cancer survivors with a disability are among the most vulnerable in health status and financial hardship, but no prior research has systematically examined how disability modifies health-care use and costs. This study examined the association between functional disability among cancer survivors and their health-care utilization and medical costs. We generated nationally representative estimates using the 2015-2019 Medical Expenditure Panel Survey. Outcomes included use of 6 service types (inpatient, outpatient, office-based physician, office-based nonphysician, emergency department, and prescription) and medical costs of aggregate services and by each of 6 service types. The primary independent variable was a categorical variable for the total number of functional disabilities. We employed multivariable generalized linear models and 2-part models, adjusting for sociodemographics and health conditions and accounting for survey design. Among cancer survivors (n = 9359; weighted n = 21 046 285), 38.8% reported at least 1 disability. Compared with individuals without a disability, cancer survivors with 4 or more disabilities experienced longer hospital stays (adjusted average marginal effect = 1.14 days, 95% confidence interval [CI] = 0.55 to 1.73), more visits to an office-based physician (average marginal effect = 1.43 visits, 95% CI = 0.51 to 2.35), and a greater number of prescriptions (average marginal effect = 12.1 prescriptions, 95% CI = 9.27 to 15.0). Their total (average marginal effect = $9537, 95% CI = $5713 to $13 361) and out-of-pocket (average marginal effect = $639, 95% CI = $79 to $1199) medical costs for aggregate services were statistically significantly higher. By type, disability in independent living was most strongly associated with greater costs for aggregate services. Cancer survivors with a disability experienced greater health-care use and higher costs. Cancer survivorship planning for health care and financial stability should consider the patients' disability profile.

Subanalysis of the CYP-GUIDES Trial: CYP2D6 Functional Stratification and Operational Timeline Selection

CYP-GUIDES (Cytochrome Psychotropic Genotyping Under Investigation for Decision Support) was a Randomized Controlled Trial comparing 2 outcomes in hospitalized patients with major depressive disorder treated according to the patient's CYP2D6 genotype and functional status versus standard psychotropic therapy. The primary outcome was hospital Length of Stay (LOS) and the secondary was Re-Admission Rate (RAR) 30 days after discharge. Methodology, total results and database of the trial have been published. Here we present a subanalysis that isolated 3 confounders to assess the impact of CYP2D6 therapeutic guidance on LOS: a single Electronic Medical Record, a minimum 3-day LOS, and CYP2D6 functional stratification of patients.CYP2D6 functional stratification enabled subgrouping patients and comparing outcomes according to CYP2D6 functionality within Group G and Group S. Subfunctional patients evidenced a 2-day shorter LOS in Group G compared to Group S. Drug administration for subfunctional patients in Group S evidenced a higher percentage of CYP2D6 substrate psychotropics being prescribed as well as a greater number of prescriptions than in functional patients.We conclude that there was an effect of pharmacogenetic clinical decision support that reduced LOS in patients with CYP2D6 subfunctional status and reduced prescribing of CYP2D6 substrate dependent drugs.

Utilization of Asynchronous and Synchronous Teledermatology in a Large Health Care System During the COVID-19 Pandemic.

Background: Teledermatology offers an opportunity to continually deliver care during the coronavirus disease 2019 pandemic. Objective: To provide quantitative data about the use of teledermatology. Methods: Retrospective analysis of teledermatology consultations was performed from March 16 to May 1, 2020. The number/type of encounters, differences in diagnoses, and prescriptions between asynchronous and synchronous teledermatology visits were analyzed. Results: A total of 951 visits (36.2%) were asynchronous whereas 1,672 visits (63.8%) were synchronous. Only 131 (<5%) visits required an acute in-person follow-up. The diagnosis of acne was more frequent with asynchronous visits (p < 0.002, Bonferroni corrected). Antibiotics and nonretinoid acne medications were prescribed more with asynchronous visits, whereas immunomodulators and biologics were more commonly prescribed with synchronous visits (p < 0.02, Bonferroni corrected). Providers at our institution were split on preferred mode (54.2% synchronous, 45.8% asynchronous); however, synchronous visits were preferred for complex medical dermatology patients and return patients (p < 0.05). Limitations: This study is limited by being a single-center study. Conclusions: Asynchronous teledermatology was used more for acne management, whereas synchronous teledermatology was preferable to providers for complex medical dermatology. Postanalysis of the data collected led us to institute a hybridization of our asynchronous and synchronous teledermatology.

Drug-related problems: An observational study at an Integrated Health Center

Failure in drug therapy can cause damage to the patient's health, becoming a real public health problem. The aim of this study was to evaluate a prevalence of DRP in patients of the Integrated Health Center of the University Anhembi Morumbi, São Paulo, Brazil. Medical records of twenty-eight patients were assessed using the Dáder Method from March to September 2019. Gender, age, weight, height, lifestyle and drug therapy were used to profile these patients. The highest concentration of patients aged 54 to 78 years old and the gender profile was 85.2% female and 14.8% male. The proportional ratio was verified when evaluating the profiles of the patients with some report of DRP being, 78.6% female and 21.4% male. The greatest number of prescriptions were observed in neurology and rheumatology, being 50.0% prescriptions of neurology and 32.0% of rheumatology. The specialties with more prescriptions with any identified DRP, with 21.4% were neurology and rheumatology. The DRP1 was the most recurrent in the prescriptions evaluated, followed by DRP5 and DRP6, followed by general practitioner. Further studies are needed to assist in the development of new instruments for the classification and prevention of risks related to medicines, especially in places where there is no pharmacotherapeutic segment, an important practice in reducing medication errors

Non-Orthopedic Encounters Increase Opioid Exposure in Joint Osteoarthritis: A Single-Institution Analysis

BackgroundThere has been little-to-no evidence to support the use of opioid analgesia as a treatment modality for osteoarthritis (OA). Chronic opioid use has been associated with peri-operative and post-operative complications with joint reconstruction. The purpose of this study is to compare opioid-prescribing habits for OA between orthopedic and non-orthopedic physicians to identify encounters that increase opioid exposure. MethodsA retrospective chart review was performed on opioid-naive adult patients with outpatient opioid prescriptions for OA at a single academic institution between 2013 and 2018. Patients with prior surgery or opioid prescriptions were excluded. Independent t-tests and analysis of variance were used to compare prescription characteristics among providers. ResultsA total of 9625 opioid prescriptions were identified. Non-orthopedic providers account for 92% of prescriptions vs 8% by orthopedic surgeons. The greatest number of prescriptions is written by Internal Medicine (37.1%) and Family Medicine physicians (36.0%). Non-orthopedic physicians prescribe a greater number of prescriptions per patient, dosages, and refills (P < .001 for all). Non-orthopedic encounters are associated with increased risk for prescription dosages ≥50 MME/d (odds ratio 5.81, 95% confidence interval 4.35-7.81, P < .001) and 90 MME/d (odds ratio 18.2, 95% confidence interval 4.43-35.70, P < .001). ConclusionThe majority of opioid prescriptions for OA are written by non-orthopedic providers, with higher prescription rates, dosages, and more refills than orthopedic surgeons. OA is a common condition that will benefit from multi-disciplinary awareness to minimize unnecessary opioid exposure and reduce potential complications with joint arthroplasty.

Preoperative Risk Factors for Opioid Utilization After Total Hip Arthroplasty

Opioid prescriptions following orthopaedic procedures may contribute to the opioid epidemic in the United States. Risk factors for greater and prolonged opioid utilization following total hip arthroplasty have yet to be fully elucidated. We sought to determine the prevalence of preoperative and postoperative opioid utilization in a cohort of patients who underwent total hip arthroplasty and to identify preoperative risk factors for prolonged utilization of opioids following total hip arthroplasty. A cohort study of patients who underwent primary elective total hip arthroplasty at Kaiser Permanente from January 2008 to December 2011 was conducted. The number of opioid prescriptions dispensed per 90-day period after total hip arthroplasty (up to 1 year) was the outcome of interest. The risk factors evaluated included preoperative analgesic medication use, patient demographic characteristics, comorbidities, and other history of chronic pain. Poisson regression models were used, and relative risks (RRs) and 95% confidence intervals (CIs) are presented. Of the 12,560 patients who underwent total hip arthroplasty and were identified, 58.5% were female and 78.6% were white. The median age was 67 years (interquartile range, 59 to 75 years). Sixty-three percent of patients filled at least 1 opioid prescription in the 1 year prior to the total hip arthroplasty. Postoperative opioid use went from 88.6% in days 1 to 90 to 24% in the last quarter. An increasing number of preoperative opioid prescriptions was associated with a greater number of prescriptions over the entire postoperative period, with an RR of 1.10 (95% CI, 1.10 to 1.11) at days 271 to 360. Additional factors associated with greater utilization over the entire year included black race, chronic pulmonary disease, anxiety, substance abuse, and back pain. Factors associated with greater utilization in days 91 to 360 (beyond the early recovery phase) included female sex, higher body mass index, acquired immunodeficiency syndrome, peripheral vascular disease, and history of non-specific chronic pain. We identified preoperative factors associated with greater and prolonged opioid utilization long after the early recovery period following total hip arthroplasty. Patients with these risk factors may benefit from targeted multidisciplinary interventions to mitigate the risk of prolonged opioid use. Opioid prescriptions following orthopaedic procedures are one of the leading causes of chronic opioid use; strategies to reduce the risk of misuse and abuse are needed. At 1 year postoperatively, almost one-quarter of patients who underwent total hip arthroplasty used opioids in the last 90 days of the first postoperative year, which makes understanding risk factors associated with postoperative opioid utilization imperative.

Profile of medicines used via oral and gastrointestinal catheter in a Walk-in Service.

To identify the profile of drugs prescribed via oral and gastrointestinal catheter in a Walk-in Service of a University Hospital. Quantitative cross-sectional study in which data were collected from the medical records of hospitalized patients using medication via oral or gastrointestinal catheter at least once a day between April and October 2015. The analysis was performed through descriptive statistics. Out of 568 prescriptions (total), there were 143 different medications. The pharmaceutical form with the greatest number of prescriptions was solid (95.8%), of which 46.1% were simple tablets. The oral route had the highest number of administrations (97.3%). The most prescribed drug class was of anti-infectives (25.9%), but the Omeprazole drug was the most prescribed in the study (40%). There are indications that enable rethinking the care practice and establishing criteria and norms for contributing to the safety and efficacy of services provided in healthcare, especially regarding the preparation and administration of medications via gastrointestinal catheter.

Domperidone use and risk of primary liver cancer in the Clinical Practice Research Datalink

BackgroundPronounced sex-disparity in liver cancer suggests a role for hormones, one of which could be prolactin. Stimulation of prolactin production in mice via domperidone has been reported to decrease hepatocarcinogenesis, thus may have chemopreventive potential. To study the effect of domperidone in humans, a large medical records study was conducted. MethodsBased in the Clinical Practice Research Datalink, 1921 liver cancer cases and 7681 controls were identified. Conditional logistic regression was employed to estimate odds ratios (OR) and 95% confidence intervals (CI). Domperidone use was analyzed overall, and by number of prescriptions and cumulative dose. ResultsComparing ever- versus never-use, there was no association between domperidone and liver cancer among men (OR = 1.06, 95% CI: 0.76–1.48) or women (OR = 1.21, 95% CI: 0.82–1.76). Among men, there was no association with dose or number of prescriptions, while among women who received the highest doses (OR2700 mg vs. 0 mg = 2.52, 95% CI: 1.18–5.41, p-trend = 0.02) and greatest number of prescriptions (OR≥11 Rx vs. 0 Rx = 3.17, 95% CI: 1.07–9.40, p-trend = 0.02) there was a significantly increased risk, although there was no evidence of heterogeneity in the results by gender. ConclusionDomperidone use was not associated with decreased liver cancer risk among all study participants. Among women, an increased risk at highest levels of exposure warrants further study.

How Do Emergency Physicians Interpret Prescription Narcotic History When Assessing Patients Presenting to the Emergency Department with Pain?

Narcotics are frequently prescribed in the Emergency Department (ED) and are increasingly abused. Prescription monitoring programs affect prescribing by Emergency Physicians (EPs), yet little is known on how EPs interpret prescription records. To assess how EPs interpret prescription narcotic history for patients in the ED with painful conditions. DESIGN/MAIN Outcome Measures: We created an anonymous survey of EPs consisting of fictitious cases of patients presenting to the ED with back pain. For each case, we provided a prescription history that varied in the number of narcotic prescriptions, prescribing physicians, and narcotic potency. Respondents rated how likely they thought each patient was drug seeking, and how likely they thought that the prescription history would change their prescribing behavior. We calculated κ values to evaluate interobserver reliability of physician assessment of drug-seeking behavior. We collected 59 responses (response rate = 70%). Respondents most suspected drug seeking in patients with greater than 6 prescriptions per month or greater than 6 prescribing physicians in 2 months. Medication potency did not affect physician interpretation of drug seeking. Respondents reported that access to a prescription history would change their prescribing practice in all cases. κ values for assessment of drug seeking demonstrated moderate agreement. A greater number of prescriptions and a greater number of prescribing physicians in the prescription record increased suspicion for drug seeking. EPs believed that access to prescription history would change their prescribing behavior, yet interobserver reliability in the assessment of drug seeking was moderate.

Multiple Prescriptions Linked to Bipolar Patients' Hospital Visits

Back to table of contents Previous article Next article Clinical & Research NewsFull AccessMultiple Prescriptions Linked to Bipolar Patients' Hospital VisitsAaron LevinAaron LevinSearch for more papers by this authorPublished Online:3 Feb 2006https://doi.org/10.1176/pn.41.3.0022aPolypharmacy—a term that leaves many clinicians and patients queasy—is often the rule in treating bipolar illness, yet the consequences of using more than one drug or switching between drugs are often unexamined, said psychiatrist Arthur Lazarus, M.D., M.B.A., at the annual meeting of the American Public Health Association in Philadelphia in December.Lazarus and seven colleagues conducted a retrospective cohort study of patients with bipolar diagnoses seen at the Henry Ford Health System in Michigan and found that more than one-third had histories of switching prescriptions or receiving concomitant prescriptions. Patients prescribed at least two psychotropic medications were more likely to be hospitalized or visit the emergency room, they found. Black patients were more likely to receive at least two psychotropic medications and more likely to go to emergency departments or hospitals, compared with non-black patients. They were also more likely to be diagnosed with Axis I psychiatric disorders, to be female, and to be eligible for Medicaid, compared with non-blacks.“I think these results demonstrate the need for more research and re-examination of treatment guidelines for bipolar disorder,” said Lazarus, senior director for neuroscience clinical research at AstraZeneca.The need for more than one drug should not be surprising, given the need to treat different phases of bipolar disorder and to stabilize mood. Only one combination drug, composed of an existing antidepressant and antipsychotic, is now approved by the Food and Drug Administration, said Lazarus in an interview.The researchers examined records covering continuous enrollment from one year prior to the date of the index prescription to one year after that date. Patients had to be at least 19 years old, meet criteria for bipolar disorder in the International Classification of Diseases, Ninth Revision (ICD-9), and have at least one prescription for drugs in four classes: anticonvulsants, mood stabilizers, first-generation antipsychotics, and second-generation antipsychotics.The 1,113 patients included in the study averaged 44.3 years old. About 61 percent were women, 29 percent were black, 68 percent were white, and 2.5 percent were listed as “other” by race. Patients were stratified into black and non-black categories. Approximately one-third had cardiovascular morbidities, and 13 percent were substance abusers. Many of these patients had previously received other psychiatric diagnoses, which may indicate a high rate of misdiagnosis of bipolar disorder, said Lazarus.About 10 percent of all patients received drugs in at least two of the four medication classes at the index date, and 36.6 percent received two or more psychotropic drugs during follow-up. However, there were statistically significant racial differences in prescribing patterns. About 12.6 percent of black patients and 8.5 percent of non-black patients received at least two drugs at the index date, and 41.1 percent of black patients and 34.7 percent of non-black patient got at least two drugs at any time.Almost half the patients (44.2 percent) had at least one emergency department visit or hospitalization in the first year of follow-up. However, patients on multiple drug regimens were more likely to be seen in those settings than those on one or no drugs.More than half (53.1 percent) of black patients had a hospitalization/emergency department visit during the first year's follow-up, compared with 40.5 percent of non-black patients (p<0.001). The mean total health care costs of $11,836 per patient in the year following index date did not differ by race.The findings may indicate that patients on two or more drugs had more severe illness and that the greater number of prescriptions was an appropriate response to that severity, said Lazarus. In contrast, they may also reflect more familiar health care disparities. The study did find that black patients were more likely to get prescriptions from emergency room physicians, an indication that they lack regular providers and continuity of care.Currently, said Lazarus, several differing guidelines address the care of patients with bipolar disorder, which may cause confusion or undertreatment.“ We need to develop practical guidelines that both physicians and patients can adhere to,” said Lazarus.A full version of Lazarus's APHA talk has been accepted for publication by Psychiatric Services and is scheduled for publication later this year. ▪ ISSUES NewArchived

The population's use of pharmaceuticals.

In this study, population-based analysis is used to study the extent to which characteristics such as age, sex, socioeconomic status, and region of residence are associated with different patterns of pharmaceutical use. It also includes an examination of whether pharmaceutical use is responsive to differential health needs across the population. Indicators of access, intensity of use, and total expenditures are used to describe Manitobans' use of pharmaceutical agents, consistent with the POPULIS framework. Several rate-based measures have been developed for this purpose: the number of residents who are pharmaceutical users; the number of prescriptions dispensed; the number of different drugs dispensed; the total number of defined daily doses (DDDs) dispensed; and expenditures for pharmaceuticals. The DDD measurement provides a cumulative assessment of total drug use (i.e., across multiple drug categories) and is a useful indicator of a population's total drug exposure. Patterns of use of pharmaceuticals follow patterns similar to those patterns in earlier POPULIS studies on health care access, intensity, and expenditures. In areas where health is generally poorer, a greater number of prescriptions are dispensed. The highest use of pharmaceuticals also was found in the lower-income quintiles and among those at greatest socioeconomic risk, traditionally those with the poorest health status. This kind of population-based pharmaceutical information can help monitor the effectiveness of policy initiatives, as well as serve to better manage pharmaceutical use within the health care system.