Inappropriate Drug Prescribing Research Articles

Improving first responders' psychogenic nonepileptic seizures diagnosis accuracy: Development and validation of a 6-item bedside diagnostic tool.

Epileptic seizures (ES) are often seen as a medical emergency, and their immediate and accurate recognition are pivotal in providing acute care. However, a number of clinical situations may mimic ES, potentially leading to misdiagnosis at the emergency room and to inappropriate prescription of antiepileptic drugs (AED) in the acute and chronic settings. Psychogenic nonepileptic seizures (PNES) play a major role in this scenario and often delay the correct diagnosis and increase treatment morbidity and cost. First responders often conduct the initial assessment of these patients, and their impression may be decisive in the prehospital approach to seizures. We sought to investigate and improve the accuracy of PNES diagnosis among professionals involved in the initial assistance to patients with seizures. Fifty-three registered nurses, 34 emergency physicians, 33 senior year medical students, and 12 neurology residents took a short training program consisting of an initial video-based seizure assessment test (pretest), immediately followed by a 30-minute presentation of a 6-item bedside diagnostic tool and then a video-based reassessment (posttest). Baseline status and learning curves were determined. The distinct professional categories showed no significant differences in their ability to diagnose PNES on both pretests and posttests. All groups improved diagnostic skills after the instructional program. The findings helped determine the best identifiable PNES clinical signs and to provide initial validation to a novel diagnostic instrument. In addition, our results showed that educational measures might help in the identification of PNES by first responders, which may decrease the treatment gap.

Predicting risk of adverse drug reactions in older adults.

Adverse drug reactions (ADRs) are common in older adults, with falls, orthostatic hypotension, delirium, renal failure, gastrointestinal and intracranial bleeding being amongst the most common clinical manifestations. ADR risk increases with age-related changes in pharmacokinetics and pharmacodynamics, increasing burden of comorbidity, polypharmacy, inappropriate prescribing and suboptimal monitoring of drugs. ADRs are a preventable cause of harm to patients and an unnecessary waste of healthcare resources. Several ADR risk tools exist but none has sufficient predictive value for clinical practice. Good clinical practice for detecting and predicting ADRs in vulnerable patients includes detailed documentation and regular review of prescribed and over-the-counter medications through standardized medication reconciliation. New medications should be prescribed cautiously with clear therapeutic goals and recognition of the impact a drug can have on multiple organ systems. Prescribers should regularly review medication efficacy and be vigilant for ADRs and their contributory risk factors. Deprescribing should occur at an individual level when drugs are no longer efficacious or beneficial or when safer alternatives exist. Inappropriate prescribing and unnecessary polypharmacy should be minimized. Comprehensive geriatric assessment and the use of explicit prescribing criteria can be useful in this regard.

Risk of inappropriate drug monitoring and prescribing in UK surgeries revealed

Risk of inappropriate drug monitoring and prescribing in UK surgeries revealed

Inappropriate Drug Prescribing in Older Adults: How to Reduce It?

Because older patients are more vulnerable to adverse drug-related events, there is a need to ensure appropriate pharmacotherapy in these patients. Screening to identify older patients at risk of drug-related problems (DRP) and adverse drug reactions (ADR) is the first critical step within a multistep approach to geriatric pharmacotherapy.

Appropriateness of pharmacological treatment in older people with dementia

Dementia is associated with a number of comorbidities often observed in older people, including hypertension, cardiovascular disease, stroke and diabetes. Treating these comorbidities in older adults with dementia results challenging for many reasons. First, older adults with dementia are generally excluded from clinical trials, so application of clinical guidelines for treatment of chronic diseases in this population might lead to polypharmacy and adverse drugs effects. Second, memory, intellectual function, judgment and language are commonly impaired in patients with cognitive deficits, compromising the compliance to complex pharmacological regimens, increasing the risk of adverse drug reactions. Third, cognitive impairment is associated with limited life expectancy and therefore limits the efficacy of pharmacological treatments and questions the appropriateness of treatment. In the present study we examine most relevant concerns related to the treatment of comorbidities in demented patients, referring also to the existing criteria for inappropriate drugs in the elderly. The application of such instruments, along with the comprehensive geriatric assessment of the older adult with cognitive impairment, could result useful to reduce the burden of polypharmacy and inappropriate drug prescriptions.

Appropriateness of Prescriptions of Recommended Treatments in Organisation for Economic Co-operation and Development Health Systems: Findings Based on the Long-Term Registry of the European Society of Cardiology on Heart Failure

ObjectiveThis observational study aimed to identify clinical variables and health system characteristics associated with incomplete guideline application in drug treatment of patients with chronic heart failure (HF) across 15 countries. MethodsThree data sets were used: European Society of Cardiology Heart Failure Registry, Organisation for Economic Co-operation and Development’s Health System Characteristics Survey, and Organisation for Economic Co-operation and Development Health Statistics 2013. Patient and country variables were examined by multilevel, multiple logistic regression. The study population consisted of ambulatory patients with chronic HF and reduced ejection fraction. Inappropriateness of prescription of pharmacological treatments was defined as patients not prescribed at least one of the two recommended treatments (angiotensin-converting enzyme inhibitors/angiotensin-receptor blockers and beta-blockers) or treated with both medications but at suboptimal dosage and in absence of documented contraindication/intolerance. ResultsOf 4605 patients, 1097 (23.8%) received inappropriate drug prescriptions with a large variation within and across countries, with 18.5% of the total variability accounted for by between-country health structure characteristics. Patient-level characteristics such as having mitral regurgitation (odds ratio 1.4; 95% confidence interval 1.1–1.7) was significantly associated with inappropriate prescription of recommended drugs, whereas chronic obstructive pulmonary disease (odds ratio 0.7; 95% confidence interval 0.5–0.9) was associated with more appropriate prescriptions. Among the country-level variables, incentives or obligation to comply with guidelines increased the probability of prescription appropriateness. ConclusionsCombining clinical variables with health system characteristics is a promising exercise to explain the appropriateness of recommended drug prescriptions. Such an understanding can help decision makers to design more effective policies to improve adherence to guidelines, improve health care outcomes, and potentially reduce costs.

Role of community pharmacists in the detection of potentially inappropriate benzodiazepines prescriptions for insomnia.

The appropriate management of chronic insomnia is crucial and prescribing of hypnotic drugs is common. Regular and prolonged use of hypnotics should be avoided because of the risk of tolerance to effects, dependence and an increased risk of adverse events. In 2012, updated Beers criteria for potentially inappropriate medication in older adults suggested to avoid all benzodiazepines in older adults to treat insomnia. In addition, successful discontinuation may result in improvements on cognitive and psychomotor function, particularly in older people. To investigate the appropriateness of benzodiazepines prescription for insomnia and explore the role that community pharmacists can have in identifying signals of potential inappropriate drug prescriptions. Community pharmacies in Italy. This is an observational study conducted in 8 community pharmacies. Each pharmacist was asked to interview a sample of patients with the prescriptions of at least one benzodiazepine and to complete a minimum data set collecting information about socio-demographic characteristics, drug indication, duration of drug prescription, number of hypnotic-drugs, previous attempt to drug-discontinuation, preference of patients about benzodiazepine withdrawal and modality of drug tapering. Main outcome measure Indications, treatment duration, dosage and drug discontinuation attempts and modalities. A total of 181 participants were interviewed. About half of respondents (n = 81) reported to be treated for insomnia and 62 % were elderly (mean age 68, range 27-93). Fifty-two patients (64 %) were on long term treatment (>3 years) while for thirteen patients (16 %) duration of treatment was comprised between 1 and 3 years. Thirty-three patients were in favour of benzodiazepine-discontinuation but in all cases discontinuation was unsuccessful. Use of community pharmacy survey data allowed us to obtain information about incorrect management of insomnia and inappropriate benzodiazepines prescriptions. Stricter adherence to evidence-based guidelines is essential for a rational use of hypnotic and sedatives.

Improvement of pharmacological treatments in nursing homes: medication review by consultant pharmacists

ObjectivesTo establish a medication review programme in geriatric patients in nursing homes.Methods70 nursing homes, attended by 8 healthcare teams; two consultant pharmacists provide training and support. Prospective study, conducted between...

Prescribing Pattern of Drugs in the Geriatric Patients in Jazan Province, KSA

Inappropriate drug prescribing is a global problem affecting the healthcare system. This study was performed to assess the drug prescribing pattern in elderly persons as these are exposed to polypharmacy because of multiple chronic conditions. There are a lot of risk factors for polypharmacy which include age, sex, race, health status, educational level and a number of chronic diseases which generally come with increasing age. This study was carried out to find rational use of prescribed drugs in the diseases with respect to the elderly patients registered in General Hospital of Jazan, KSA and to also investigate polypharmacy. A prospective, cross-sectional study was carried out in hospitalized elderly patients (age, >65 years) selected from the month of November 2012 to October 2013 which consists of: Drug prescription pattern as per Beer's criteria, Percentage of category of drugs prescribed as per WHO core indicator, Missing Item Prevalence. Among 1034 elderly patients, the average age of study patients was 72 years. The diseases found during this study were, hypertension, GIT disorders, cardiovascular diseases, respiratory tract diseases, diabetes mellitus. The average number of diseases present is 4+1 and the average number of drugs overall was 7+1. Among systemic route, commonly prescribed therapeutic class of medications were antibacterials (70.5%) and among oral route, pantoprazole was the most commonly prescribed medication (61.2%). This study demonstrates the prescribing patterns of drugs and usage of drugs in the elderly patients in the Jazan region of Saudi Arabia.

Organizational Factors Associated With Inappropriate Neuroleptic Drug Prescribing in Nursing Homes: A Multilevel Approach

ObjectiveTo determine whether the number of attending general practitioners (GPs) in nursing homes and other facility characteristics are associated with inappropriate neuroleptic prescribing. DesignCross-sectional study. SettingOne hundred seventy-five nursing homes in France participating in the IQUARE (Impact d'une démarche QUAlité sur l'évolution des pratiques et le déclin fonctionnel des Résidents en EHPAD) study. ParticipantsA total of 6275 residents included between May and July 2011. MeasurementsThe outcome measure was potentially inappropriate prescribing of neuroleptic drugs according to the approved indications and French guidelines. Resident characteristics and nursing home characteristics were electronically recorded by the nursing home's coordinating physician. Because of the hierarchical structure of data (resident level and nursing home level), multivariate analysis using a multilevel binary logistic model was carried out to investigate factors associated with inappropriate neuroleptic prescribing. ResultsOf 6275 residents enrolled, 1532 (24.4%) had at least 1 prescription for a neuroleptic drug. This corresponded to 513 residents (33.5%) with appropriate prescribing (with regard to indication, substance and dose) and 1019 (66.5%) with potentially inappropriate prescribing. The multilevel binary logistic model showed that residents who lived in a nursing home with 30 GPs or more/100 beds had a higher likelihood of potentially inappropriate prescription than those who lived in nursing homes with fewer than 10 GPs/100 beds [adjusted odds ratio (aOR) 1.80; 95% confidence interval (CI) 1.04–3.12]. Residents who were ≥85 years old and those with dementia were more likely to have inappropriate prescription (aOR 1.75; 95% CI 1.32–2.32 and aOR, 2.06; 95% CI 1.56–2.74, respectively) such as the statement “no psychotropic drug prescription,” whereas the resident did in fact have a prescription (aOR 1.96; 95% CI 1.03–3.74). ConclusionsOrganizational difficulties because of a large number of physicians probably explain the association with inappropriate prescribing of neuroleptics.

Prescription of potentially inappropriate drugs for geriatric patients in long-term care: improvement through pharmacist's intervention

ObjectivesTo determine the prevalence of potentially inappropriate prescribing in our long-term care institutions with limited experience of pharmacists’ interventions. To apply preventative measures, based on pharmacists’ recommendations, to obtain better...

Adecuación terapéutica en pacientes crónicos

Therapeutic appropriateness in chronic patients Inappropriate prescribing is an important health problem in patients with chronic diseases, usually elderly, due to its association with health deterioration, loss of functional capacity and quality of life, and increased mortality. Although there are multiple variables related to potentially inappropriate prescribing, polypharmacy is the main associated factor. For all of the above, it is necessary to implement actions in daily clinical practice aimed at improving therapeutic appropriateness and reducing inappropriate drug prescription. This strategy should start at the moment of prescription, having different tools to help to review the adequacy of previously prescribed medication. Any intervention must begin with an individualized analysis of the situation, and must have the patient’s approval, especially in the case of drug withdrawal. Furthermore, these review actions should be periodically repeated, given the changing circumstances in the state of health, the therapeutic goals and the patient’s perspective. . Various studies have been carried out in order to evaluate such interventions, having demonstrated improvements in intermediate outcomes (reduction of potentially inappropriate prescribing), but with little published data on outcomes in terms of health status. There is consensus on the need to continue with its implementation.

Réhospitalisations d’origine médicamenteuse : étude pilote dans un service de post-urgences médicales d’un hôpital universitaire français

PurposeAdverse Drug Reactions (ADRs) leading to hospital admission was estimated to 3.6 to 21.7%. Despite its importance in terms of patients care, readmission to hospital due to ADRs remains poorly documented. The aim of our study was to investigate the rate and main characteristics of readmission for ADRs. MethodsWe undertook a retrospective study during two years (2011–2012) in the post-emergency unit of Toulouse university hospital (south western, France). We selected all unplanned hospitalization for acute disease and included all cases of patients admitted twice fold or more for ADRs. Characteristics of drug-induced ADRs were assessed according to appropriate use or not. ResultsOut of the 197 readmitted patients, 71 was related to ADRs (3.6%) corresponding to 17.8‰ patients-year. Mean age was 82.3 years and 67% were women. The most frequent ADRs found were vascular (n=41, 18.4%), gastro-intestinal (n=28, 12.6%), cardiac (n=28, 12.6%), neurologic (n=26, 11.7%), metabolic (n=26, 10.3%) and psychiatric (n=24, 9.9%). The drugs mainly involved were psychoactive, cardiovascular, digestive or antithrombotic agents. The context of occurrence of ADRs was related to inappropriate drug prescription in 56% of cases. A total of 24 patients were admitted twice for the same ADR and 2 others three times. For 22 patients (30.9%), the same drugs were involved. ConclusionOur data show hospital readmission was due to ADRs in 3.6% of cases. In 1.1% of cases, the same couple “drug–ADR” was involved. Furthermore, in 56% of cases, repeated admissions are related to an inappropriate drug prescription.

Potentially Inappropriate Drug Prescribing and Associated Factors in Nursing Homes

ImportancePolymedication is frequent in nursing home (NH) residents. This increases the risk of potentially inappropriate drug prescribing (PIDP), which can lead to adverse drug events, such as falls and hospitalization. ObjectiveTo identify PIDP in NH residents and to investigate subject-related and NH structural and organizational factors associated with PIDP. DesignCross-sectional study. SettingA total of 175 NHs in Midi-Pyrénées region, South-Western France. ParticipantsA total of 974 subjects randomly selected from the 6275 NH residents participating in the IQUARE study. ExposurePatients with PIDP. Main Outcomes and MeasuresPIDP was the main outcome measure. It was defined using a specific indicator, based on the Summary of Product Characteristics, on the Laroche list, and on residents' clinical data. PIDP was defined as the presence of at least 1 of the following criteria: (1) drug with an unfavorable benefit-to-risk ratio; (2) drug with questionable efficacy according to the Laroche list; (3) absolute contraindication; (4) significant drug-drug interaction. Associated factors were identified by using multivariable logistic regression models. ResultsAmong the 974 residents included, 71% had PIDP. PIDP was more frequent in patients without dementia, with several comorbidities and taking multiple medications. In the multivariable analysis, age (odds ratio [OR] 1.02; 95% confidence interval [CI] 1.01–1.03) and Charlson Comorbidity Index (CCI; P = .003, CCI = 1 versus 0: OR1/0 1.22; 95% CI 0.85–1.74, CCI ≥ 2 versus 0: OR2/0 1.72; 95% CI 1.23–2.41) were associated with an increased likelihood of PIDP. By contrast, dementia was associated with a lower likelihood of PIDP (OR 0.70; 95% CI 0.53–0.94). Among NH structural and organizational characteristics, the access to psychiatric advice and/or to hospitalization in a psychiatric unit (OR 1.36; 95% CI 1.02–1.82) and the presence of a reevaluation of drug prescriptions (OR 1.45; 95% CI 1.07–1.96) were associated with an increased likelihood of PIDP. Conclusions and RelevanceOur work suggests that some NH characteristics are associated with an increased likelihood of PIDP. Gaining a better understanding of the factors influencing PIDP, especially structural and organizational NH factors, can help to determine the interventions that should be implemented.

Inappropriate drug prescription in elderly nursing home residents

Background The elderly are largely affected by one or more chronic diseases; they often receive medications, thus being widely exposed to the possibility of adverse drug reactions. Adverse drug reactions could be curtailed by lowering inappropriate prescription; the international community uses the Beers Criteria to identify those potentially harmful drugs, whose prescription should therefore be avoided. The present assessment, which represents the first phase of a project aimed to reduce the phenomenon of inappropriate prescribing, quantifies the prescription of …

An Educational Intervention on Drug Use in Nursing Homes Improves Health Outcomes Resource Utilization and Reduces Inappropriate Drug Prescription

ObjectiveInappropriate drug prescription is a common problem in people living in nursing homes and is linked to adverse health outcomes. This study assessed the effect of an educational intervention directed to nursing home physicians in reducing inappropriate prescription and improving health outcomes and resource utilization. DesignProspective, randomized, multicenter study. SettingA private organization of nursing homes in Spain. ParticipantsSixty nursing home physicians caring for approximately 3900 nursing home residents in 37 centers were randomized to receive an educational intervention (30) or as a control group (30). Intervention10 hours educational program, followed by on demand support by phone. Outcome MeasurementsOutcomes were assessed in 1018 randomly selected nursing home residents. Appropriateness of drug use [measured by the Screening Tool of Older Persons Prescriptions (STOPP) and Screening Tool to Alert Doctors to Right Treatment (START) criteria], incidence of selected geriatric syndromes (falls, delirium) and health resource utilization (visits to physicians and nursing homes, visits to the emergency room, days of hospitalization) were recorded for 3 months before the intervention started and 3 months after the intervention finished. ResultsO total of 716 residents finished the study (344 cared for by the intervention group physicians, 372 cared for by control physicians). Mean age was 84.4 ± 12.7 years; 73% were women. The mean number of inappropriate drugs (STOPP criteria) was higher at the end of the study in the control than in the intervention group (1.29 ± 1.56 vs 0.81 ± 1.13), as was the number of residents on 6 or more drugs (76.5% vs.67.0%), using antipsychotics (9.1% vs 3.2%) or duplicate medications (32.5% vs 9.2%). The number of fallers increased in the control group (from 19.3% to 28%) and did not significantly change in the intervention group (from 25.3% to 23.9%); the number of residents with delirium increased in the control group (from 3.8% to 9.1%) and decreased in the intervention group (from 6.1% to 3.2%). The number of visits to a physician did not change in the control group (−0.22, P = .3) but were significantly reduced in the intervention group (−0.76, P = .01), the same happened with the number of visits to a nurse (−0.38, P = .4 in controls, −1.43 in the intervention group, P < .001). Visits to the emergency room and days in hospital significantly increased in the control group (+0.12 and +0.38) but were unchanged in the intervention group (+0.03 and +0.01). ConclusionsAn educational intervention on drug use is feasible in nursing home physicians and improves the use of inappropriate drugs, use of antipsychotics, and drug duplications in their residents. It may also improve the risk of delirium and falls, and reduce the use of health care resources.

A prospective study on ambulatory care provided by primary care pediatricians during influenza season.

Aim of this study was to obtain a picture of the nature of the primary care pediatricians’ visits during a winter season. We investigated reasons for visits, diagnosis, and pattern of prescription in 284 children. The reason for visit was a planned visit in 54% of cases, a well-being examination in 26%, and an urgent visit for an acute problem in 20% of cases. Cough was the most common symptom reported (61%). The most common pediatricians’ diagnosis was flu-like syndrome (47%). No disease was found by pediatrician in 27% of children with a symptom reported by caregivers. Antibiotics were prescribed in 25% of children, the vast majority of which affected by viral respiratory infections. The unjustified access to physician’s visit may lead to a inappropriate prescription of drugs.

CP-042 Inappropriate drug prescriptions and associated factors in Nursing Homes

BackgroundOlder people residing in nursing homes (NHs) often suffer from several comorbid conditions and cognitive and functional decline. Polymedication is frequent in this population, increasing the risk of inappropriate prescribing,...

Polypharmacy in Heart Failure Patients

In heart failure (HF), the progressive use of multiple drugs and a complex therapeutic regimen is common and is recommended by international guidelines. With HF being a common disease in the elderly, patients often have numerous comorbidities that require additional specific treatment, thus producing a heavy pill burden. Polypharmacy, defined as the chronic use of five or more medications, is an underestimated problem in the management of HF patients. However, polypharmacy has an important impact on HF treatment, as it often leads to inappropriate drug prescription, poor adherence to pharmacological therapies, drug-drug interactions, and adverse effects. The growing complexity of HF patients, whose mean age increases progressively and who present multiple comorbidities, suggests the need for newer models of primary care to improve the management of HF patients. Self-care, telemonitoring, and natriuretic peptide-guided therapy represent promising new HF care models to face the complexity of the disease and its therapeutic regimen.

Drug prescribing pattern among pregnant mothers attending obstetrics and gynecology department in Hiwot Fana Specialized Teaching Hospital, Ethiopia

Objective: To assess the pattern of prescribing and drug therapy problems among the pregnant mothers in Hiwot Fana specialized University hospital, Harar Ethiopia. Methods and subjects: Retrospective cross‑sectional study was employed to assess drug prescribing pattern and teratogenicity risk among pregnant women who received any clinical services from MCH and obstetric clinic from 11 September 2012 to 31April 2013. Result: From a total of 422 samples selected, medical records of 395 pregnant women’s were included in the study; where about 27 of the patient card was not found during data collection. Among the 395 pregnant mothers, 301 (76.2%) were outpatient and 94(23.8%) were admitted. one hundred thirty eight (34.9%) are in age group of 21‑25 and one hundred twenty five (31.6%) were third trimesters. Most frequently prescribed drug classes were antibiotics, vitamins and minerals, NSAIDS and analgesics, anti‑hypertensive’s, cardio vascular drugs and fluids. Category D and X drugs which were considered to be risky to both pregnant women and fetus were prescribed for 42 (13.08%) pregnant women. From the study participant, 169 (42.8%) had drug therapy problem. One hundred eleven (28.1%) had need of additional drug therapy while 52 (13.2%) had unnecessary drug therapy and 11(2.8%), 24 (6.1%) had high and low dosage respectively. Conclusion: Antibiotics were commonly prescribed along vitamins and minerals while there were (13.08%) category D and category X drugs prescribed inappropriately to some of the patients. Such inappropriate prescription of drugs should not be underestimated because it definitely affects the life of both the mother and the fetus.