Multiple Prescriptions Research Articles

Differentiated approach to the choice of PPI in a patient with GERD in the practice of an outpatient (with a clinical case)

In recent years, functional disorders of the gastrointestinal tract (GIT) are quite common. The most significant functional disorders are functional dyspepsia (FD), which is widespread in the population. In addition, in the clinical practice of outpatient doctors, the proportion of combined variants or overlap of several types of functional disorders or a combination of functional disorders with organic pathology has increased. So, according to systematic reviews, the combined course of gastroesophageal reflux disease (GERD) and FD occurs in at least one third of patients. At the same time, the combined functional pathology of the gastrointestinal tract changes the clinical picture of GERD, which complicates differential diagnosis, leads to inadequate and multiple prescription of drugs and often low effectiveness of the prescribed therapy. All this negatively affects the quality of life of patients. The tactics of managing patients with the combined course of GERD and FD sometimes presents certain difficulties, since there are no available recommendations for pathogenetic therapy and preventive measures. To date, possible links in the pathogenesis of both GERD and FD have been studied and described, which predetermine certain approaches to the treatment of various variants of these two diseases. Drug therapy for GERD includes the appointment of proton pump inhibitors (PPIs), antireflux drugs. In FD therapy, prokinetics and/or PPIs are effective. A rational approach in the treatment of the intersection of GERD and FD is the appointment of a drug with a dual mechanism of action, which contains both a prokinetic and a PPI. An example of this approach is the appointment of omeprazole and domperidone. The use of this drug is presented in a clinical case.

Predictors and prescribing patterns of opioid medications surrounding reverse shoulder arthroplasty.

BackgroundOpioid analgesics play an essential role in postoperative pain management; however, they are also associated with high rates of abuse and decreased patient outcomes. With the declaration of the recent opioid crisis, more scrutiny has been placed on physicians and their prescribing habits, and orthopedic surgeons have been shown to be the third-largest providers of opioids. Many patients undergoing reverse shoulder arthroplasty (RSA) have acute and chronic pain and may be prescribed opioids. The purpose of this study was to understand opioid-prescribing patterns across all specialties for patients undergoing RSA.MethodsA retrospective review of preoperative and postoperative opioid use in 407 patients who underwent RSA from 2012 to 2015 was performed. Demographic data including age, sex, race, ethnicity, body mass index, American Society of Anesthesiologists class, and smoking status were recorded. Opioid prescriptions within 90 days before and after surgery were collected using state-mandated prescription drug–monitoring databases. Prescriber specialty was recorded, and prescriptions were categorized as follows: orthopedic surgery, primary care or internal medicine, pain management and anesthesia, dentistry, and emergency medicine.ResultsThe cohort was composed of 236 women (58.0%) and 171 men (42.0%). The average age was 71 years. Forty-six percent of patients received preoperative prescriptions, of which 24.7% were written by orthopedic surgeons and 60.0% were written by internal medicine specialists. Preoperatively, 20% of patients received >3 prescriptions for opioids, and postoperatively, 36.4% of patients received >3 opioid prescriptions. Fifty-nine percent of all postoperative prescriptions were written by orthopedists, and 35.2% were written by internal medicine specialists.ConclusionNot surprisingly, orthopedic surgeons prescribed the majority of postoperative prescriptions. Increased awareness, however, of preoperative prescribing habits by other specialty providers may be needed, with communication of their prescriptions to orthopedists, as preoperative use is the strongest predictor of postoperative dependence on opioids. Physicians should be aware of the number of patients receiving multiple prescriptions and their contribution to dependence with continued refills postoperatively. Therefore, surgeons must be more meticulous in assessing opioid consumption before surgery, as well as which providers are writing prescriptions after surgery, to limit opioid dispensation.

Self-Report for Measuring and Predicting Medication Adherence: Experts' Experience in Predicting Adherence in Stable Psychiatric Outpatients and in Pharmacokinetics.

The ProblemPoor adherence to appropriately prescribed medication is a global challenge for psychiatrists.Prior StudiesMeasuring adherence is complicated. In our recent three-country naturalistic study including more than 1000 patients and their adherence to multiple medication prescriptions at the same time, patients’ self-report of adherence to each specific drug was the only practical option for measuring adherence. Systematic literature reviews provide inconsistent results for sociodemographic, clinical and medication variables as predictors of adherence to psychiatric drugs. Our studies over the last 10 years in relatively stable psychiatric outpatients have shown that some self-reported health beliefs had consistent, strong effects and a better predictive role. Three dimensions of these health beliefs are characteristics of the individual: 1) attitudes toward psychiatric medication such as pharmacophobia (fear of taking drugs or medicines), 2) health locus of control (the belief patients have about who or what agent determines the state of their health), 3) psychological reactance (an emotional reaction in direct contradiction to rules or regulations that threaten or suppress certain freedoms in behavior). They can be measured by the Patient Health Beliefs Questionnaire on Psychiatric Treatment. The attitude toward each specific medication can be measured by the necessity-concern framework and summarized as the presence or absence of skepticism about that drug. After 25 years conducting pharmacokinetic studies in psychiatric drugs, particularly antipsychotics, we have limited understanding of how to use blood levels to predict the effects of non-adherence or to establish it.Expert Opinion on Future StudiesFuture studies to predict adherence should include the inpatient setting and explore insight. Studying the pharmacokinetics associated with non-adherence in each psychiatric drug is a major challenge. Medication adherence is a complex and dynamic process changing over time in the same patient. Personalizing adherence using psychological or pharmacological variables are in their initial stages.

Multiple Perioperative Opioid Prescribers Associated with New Persistent Opioid Use after Operations Among Adolescents and Young Adults

Vargas, Gracia M. BA; Harbaugh, Calista MD, MS; Gunaseelan, Vidhya MBA, MS, MHA; Englesbe, Michael MD; Waljee, Jennifer F. MD, MPH, MS Author Information

Socioeconomic status and HRT prescribing: a study of practice-level data in England.

Concerns have been raised that women from deprived backgrounds are less likely to be receiving hormone replacement therapy (HRT) treatment and its benefits, although evidence in support of this is lacking. To investigate general practice HRT prescription trends and their association with markers of socioeconomic deprivation. Cross-sectional study of primary care prescribing data in England in 2018. Practice-level prescribing rate was defined as the number of items of HRT prescribed per 1000 registered female patients aged ≥40 years. The association between Index of Multiple Deprivation (IMD) score and HRT prescribing rate was tested using multivariate Poisson regression, adjusting for practice proportions of obesity, smoking, hypertension, diabetes, coronary heart disease and cerebrovascular disease, and practice list size. The overall prescribing rate of HRT was 29% lower in practices from the most deprived quintile compared with the most affluent (incidence rate ratio [IRR] = 0.71; 95% confidence interval [CI] = 0.68 to 0.73). After adjusting for all cardiovascular disease outcomes and risk factors, the prescribing rate in the most deprived quintile was still 18% lower than in the least deprived quintile (adjusted IRR = 0.82; 95% CI = 0.77 to 0.86). In more deprived practices, there was a significantly higher tendency to prescribe oral HRT than transdermal preparations (P<0.001). This study highlights inequalities associated with HRT prescription. This may reflect a large unmet need in terms of menopause care in areas of deprivation. Further research is needed to identify the factors from patient and GP perspectives that may explain this.

Prescription Opioid Dispensing Patterns Prior to Heroin Overdose in a State Medicaid Program: a Case-Control Study.

A large proportion of individuals who use heroin report initiating opioid use with prescription opioids. However, patterns of prescription opioid use preceding heroin-related overdose have not been described. To describe prescription opioid use in the year preceding heroin overdose. Case-control study comparing prescription opioid use with a heroin-involved overdose, non-heroin-involved opioid overdose, and non-overdose controls from 2015 to 2017. Oregon Medicaid beneficiaries with linked administrative claims, vital statistics, and prescription drug monitoring program data. Opioid, benzodiazepine, and other central nervous system depressant prescriptions preceding overdose; among individuals with one or more opioid prescription, we assessed morphine milligram equivalents per day, overlapping prescriptions, prescriptions from multiple prescribers, long-term use, and discontinuation of long-term use. We identified 1458 heroin-involved overdoses (191 fatal) and 2050 non-heroin-involved opioid overdoses (266 fatal). In the 365days prior to their overdose, 45% of individuals with a heroin-involved overdose received at least one prescribed opioid compared with 78% of individuals who experienced a non-heroin-involved opioid overdose (p < 0.001). For both heroin- and non-heroin-involved overdose cases, the likelihood of receiving an opioid increased with age. Among heroin overdose cases with an opioid dispensed, the rate of multiple pharmacy use was the only high-risk opioid pattern that was greater than non-overdose controls (adjusted odds ratio 3.2; 95% confidence interval 1.48 to 6.95). Discontinuation of long-term opioid use was not common prior to heroin overdose and not higher than discontinuation rates among non-overdose controls. Although individuals with a heroin-involved overdose were less likely to receive prescribed opioids in the year preceding their overdose relative to non-heroin opioid overdose cases, prescription opioid use was relatively common and increased with age. Discontinuation of long-term prescription opioid use was not associated with heroin-involved overdose.

Medicaid managed care plans start paying Ohio pharmacists as providers

Medicaid managed care companies are working with the Ohio Department of Medicaid to act on a 2019 law that recognizes pharmacists as providers in Ohio. Since getting wind of what pharmacists are capable of doing for patients, three Medicaid managed care plans in Ohio have launched programs of their own to pay pharmacists as medical providers. Additional plans are expected to make announcements in the coming months. In April 2020, UnitedHealthcare began working with two independent community pharmacies in Ohio to launch a program that uses the expertise of pharmacists to expand access to care for patients and drive better health outcomes for Medicaid beneficiaries. Pharmacists in the program are able to bill and receive reimbursement for providing patient care services using existing CPT codes for evaluation and management, virtual check-ins, and transitional care management. “We feel community pharmacies can do more if we create the right incentives,” said Mike Roaldi, CEO of UnitedHealthcare Community Plan of Ohio. So far, two community pharmacies are participating in the program. UnitedHealthcare selected them based on the high concentration of plan members who frequent the pharmacies. These members also have multiple prescriptions and chronic conditions. Results are being measured both qualitatively and quantitatively. “The first thing we want to do right now is prove the concept works and get outcomes—we want the data,” said Roaldi. They are keeping track of three specific quality metrics: hospital readmissions, unnecessary prescriptions, and the management of chronic conditions. “We also want stories in this early stage about how pharmacists provide better care and [prevent errors for] patients,” said Roaldi. Ohio’s Centene managed care organization, through Buckeye Health Plan, launched its program in June 2020 and during the initial phase, participating pharmacists at a health system and two federally qualified health centers are expected to work with physicians to provide care for patients who have chronic conditions. As this article went to press, another Ohio Medicaid plan, CareSource, announced a provider status program focused on two independent community pharmacies. All programs will reimburse pharmacists for clinical services. When former Ohio governor John Kasich signed SB 265 at the beginning of 2019—a law that formally recognizes pharmacists as providers in Ohio law—the work had only begun for any real change to happen for Ohio pharmacists. “Ohio’s momentum has been based on three factors,” said Stuart Beatty, PharmD, director of strategy and practice transformation at the Ohio Pharmacists Association (OPA) and associate professor of clinical pharmacy at Ohio State University College of Pharmacy. Passing legislation and the overarching changes due to health care transformation have been critical, said Beatty. But so was Ohio’s investigation of the PBM industry. Once the public became aware of the issues for pharmacies, legislators started putting pressure on payers, specifically managed care organizations (MCOs). Beatty said the timing is important to consider. During the spring of 2019, as the provider status law was still waiting to go into effect officially, legislators questioned the MCOs during an April 2019 Ohio Joint Medicaid Oversight Committee meeting that was focused on PBMs. With Ohio legislators aware of the provider status law, they also began asking how the plans were going to implement the new law. According to Beatty, the public questioning opened the door for OPA to have meaningful conversations with payers about how pharmacists are an underutilized resource. “As a result, the plans started to realize what pharmacists can do and a shift happened,” said Beatty. “This combined with a focus toward value-based care got the discussion quickly turned in Ohio about how pharmacists can help patients achieve better health outcomes with an incentive structure in place,” he continued. The Ohio Department of Medicaid announced they will create provider identification numbers for pharmacists in January 2021. Antonio Ciaccia, director of government and public affairs at OPA, said this will put “rocket fuel” in the existing Medicaid managed care plans that are already working collaboratively with pharmacists. The Ohio Department of Medicaid has begun compensating pharmacists to conduct COVID-19 testing as well. After the U.S. Department of Health and Human Services made it clear earlier this year that allowing pharmacists to order and administer FDA-authorized COVID-19 tests supersede state limits on scope of practice, Ohio governor Mike DeWine had to take action, instructing Ohio’s Medicaid program to create codes that allow pharmacies to bill for tests on program beneficiaries.

Health Information Technology and Doctor Shopping: A Systematic Review.

Doctor shopping is the practice of visiting multiple physicians to obtain multiple prescriptions. Health information technology (HIT) allows healthcare providers and patients to leverage records or shared information to improve effective care. Our research objective was to determine how HIT is being leveraged to control for doctor shopping. We analyzed articles that covered a 10-year time period from four databases and reported using preferred reporting items for systematic reviews and meta-analysis (PRISMA). We compared intervention, study design, and bias, in addition to showing intervention interactions with facilitators, barriers, and medical outcomes. From 42 articles published from six countries, we identified seven interventions, five facilitator themes with two individual observations, three barrier themes with six individual observations, and two medical outcome themes with four individual observations. Multiple HIT mechanisms exist to control for doctor shopping. Some are associated with a decrease in overdose mortality, but access is not universal or compulsory, and data sharing is sporadic. Because shoppers travel hundreds of miles in pursuit of prescription drugs, data sharing should be an imperative. Research supports leveraging HIT to control doctor shopping, yet without robust data sharing agreements, the efforts of the system are limited to the efforts of the entity with the least number of barriers to their goal. Shoppers will seek out and exploit that organization that does not require participation or checking of prescription drug monitoring programs (PDMP), and the research shows that they will drive great distances to exploit this weakest link.

Prescription History Before Opioid Overdose Death: PDMP Data and Responsible Prescribing.

As the opioid epidemic continues, state legislatures and clinicians increasingly utilize Prescription Drug Monitoring Programs (PDMPs). These programs record dates prescribed and filled for all controlled substances, attempting to identify high-risk prescribing. The aims of this study were to (i) examine data from individuals who died of accidental opioid overdose and (ii) compare differences between those with prescriptions documented in Kentucky's PDMP with individuals without recorded prescriptions. This was a retrospective, observational cohort study conducted in Jefferson County, Kentucky. We reviewed records for all opioid overdose death subjects from 2017 and 2018, cross-referencing with prescriptions in Kentucky's PDMP (Kentucky All Schedule Prescription Electronic Reporting System [KASPER]) back to 2014. We performed χ2 analyses for categorical variable comparisons and a separate univariate analysis for age. Of the 575 individuals who died of accidental opioid overdose in Jefferson County during the study period, 379 (65.9%) had prescriptions documented in KASPER. Individuals had a high prevalence of fentanyl on postmortem toxicology. Only one individual had postmortem toxicology positive for buprenorphine, a medication for opioid use disorder (MOUD). Several subjects experienced what we termed see-saw MOUD prescribing (prescriptions alternating between MOUD and other controlled substances including full agonists), and multiple prescriptions were apparently written and/or filled for deceased subjects. Review of PDMP data in deceased patients can prevent unnecessary opioid prescribing and optimize clinical practice. Buprenorphine may have a protective effect in opioid dependence, but access must be consistent. Providers should be aware of see-saw MOUD prescribing and understand the effects on patient care. In response to the prescriptions filled for deceased individuals, legislators could enact a policy such as Void All Prescriptions or VAP alerts to cancel all prescriptions for individuals who have died, reducing drug diversion. It is vital that providers routinely use PDMP data along with counseling and other treatment strategies to optimize patient care.

An exploration of attitudes and preferences towards medications among healthcare providers and persons with spinal cord injury/dysfunction: a qualitative comparison

Purpose To compare the attitudes and preferences of persons with spinal cord injury/dysfunction (SCI/D) and healthcare providers regarding prescription medications, over-the-counter medications, and natural health products (NHPs). Materials and methods A qualitative study involving semi-structured interviews with healthcare providers (n = 32) and persons with SCI/D (n = 19) in Canada. Inductive descriptive and interpretive analyses were conducted using data display matrices and a constant comparative approach. Results Participants described differing perceptions of therapeutic benefits based on medication type, with shared attitudes about the therapeutic benefits of prescription medications and differing views about the effectiveness of NHPs. Despite the perceived effectiveness of prescription medications, persons with SCI/D preferred to avoid them due to concerns about side effects, safety, and stigma. Persons with SCI/D were often concerned about the long-term safety of prescription medications, whereas providers focused more on medication-related addictions. Participants discussed stigma relating to prescription medications, NHPs, and medicinal marijuana. Conclusion Healthcare providers and persons with SCI/D described different attitudes about and preferences for pharmacotherapeutic products, contributing to challenges in optimizing medication management. Strategies to improve medication management include shared decision-making to incorporate patient preferences into care plans and explicit discussions about long-term medication safety. Further, steps are needed to combat the stigma associated with medication use. Implications for rehabilitation Following a person-centered approach to shared decision-making, prescribers should initiate explicit conversations about patient medication preferences, short and long-term prescription medication side effects, and alternative treatment options. Regarding prescription medication safety, persons with spinal cord injury/dysfunction focused on the long term impact of medications, while providers focused on medication-related addictions, highlighting a disconnect that should be discussed during initiation, continuation, or discontinuation of a medication. Providers should be mindful of the stigma associated with taking multiple prescription medications, including medicinal marijuana, as well as the stigma associated with over-the-counter medications and natural health products. Providers could benefit from education about spinal cord injury/dysfunction-specific prescription medications and could benefit from increased education about natural health products.

All-Cause Opioid Prescriptions Dispensed: The Outsized Role of Adults With Arthritis

Limited estimates of prescribed opioid use among adults with arthritis exist. All-cause (i.e., for any condition) prescribed opioid dispensed (referred to as opioid prescription in the remainder of this abstract) in the past 12 months among U.S. adults aged ≥18 years (n=35,427) were studied, focusing on adults with arthritis (n=12,875). In 2018-2019, estimates were generated using Medical Expenditure Panel Survey data: (1) 2015 prevalence of 1 or more opioid prescriptions to U.S. adults overall and by arthritis status and (2) in 2014-2015, among adults with arthritis, multivariable-adjusted associations between 1 or more opioid prescriptions and sociodemographic characteristics, health status, and healthcare utilization characteristics. In 2015, the age-standardized prevalence of 1 or more opioid prescriptions among adults with arthritis (29.6%) was almost double of that for all adults (15.4%). Adults with arthritis represented more than half of all adults (55.3%) with at least 1 opioid prescription; among those with 1 or more prescriptions, 43.2% adults had 4 or more prescriptions. The strongest multivariable-adjusted associations with 1 or more opioid prescriptions were ambulatory care visits (1-4: prevalence ratios=1.9-2.0, 5-8: prevalence ratios=2.5-2.7, 9 or more: prevalence ratios=3.4-3.7) and emergency room visits (1: prevalence ratios=1.6, 2-3: prevalence ratios=1.9-2.0, 4 or more: prevalence ratios=2.4); Ref for both: no visits. Adults with arthritis are a high-need target group for improving pain management, representing more than half of all U.S. adults with 1 or more opioid prescriptions. The association with ambulatory care visits suggests that providers have routine opportunities to discuss comprehensive and integrative pain management strategies, including low-cost evidence-based self-management approaches (e.g., physical activity, self-management education programs, cognitive behavioral therapy). Those with multiple opioid prescriptions may need extra support if transitioning to nonopioid and nonpharmacologic pain management strategies.

Deprescribing in mental health care

Deprescribing has mostly developed in older adult care as a strategy to reverse the potential harm to older adults of receiving too many inappropriate medicines. There are many studies in older adult care that show that by deprescribing medicines, prescribers are able to improve patient function, generate a higher quality of life, and reduce bothersome signs and symptoms. However, there have been few comparable studies in mental health. Overprescribing or inappropriate prescribing has also become an issue for mental health care. However, it commonly relates to psychotropic medicines and, in particular, to antidepressants, benzodiazepines, z hypnotics, antiepileptics, such as pregabalin, and to multiple psychotropic prescribing. In other areas of therapy associated with physical health, the concerns have generally been those of under prescribing. This paper discusses how relevant deprescribing is to mental health care and some of the issues to consider.

Association Between Patients' Self-Reported Gaps in Care Coordination and Preventable Adverse Outcomes: a Cross-Sectional Survey.

Whether patients' reports of gaps in care coordination reflect clinically significant problems is unclear. To determine any association between patient-reported gaps in care coordination and patient-reported preventable adverse outcomes. We administered a cross-sectional survey on experiences with healthcare to participants in the national Reasons for Geographic and Racial Differences in Stroke (REGARDS) study who were ≥ 65years old. Of the 15,817 participants in REGARDS at the time of our survey (August 2017-November 2018), 11,138 completed the survey. We restricted the sample to participants who reported ≥ 2 ambulatory visits and ≥ 2 ambulatory providers in the past year (N = 7568). We considered 7 gaps in ambulatory care coordination, elicited with previously validated questions. We considered 4 outcomes: (1) a test that was repeated because the doctor did not have the result of the first test, (2) a drug-drug interaction that occurred due to multiple prescribers, (3) an emergency department visit that could have been prevented by better communication among providers, and (4) a hospital admission that could have been prevented by better communication among providers. We used logistic regression to determine the association between ≥ 1 gap in care coordination and ≥ 1 preventable outcome, adjusting for potential confounders. The average age of the sample was 77.0years; 55% were female, and 34% were African-American. More than one-third of participants (38.1%) reported ≥ 1 gap in care coordination and nearly one-tenth (9.8%) reported ≥ 1 preventable outcome. Having ≥ 1 gap in care coordination was associated with an increased odds of ≥ 1 preventable outcome (adjusted odds ratio 1.55; 95% confidence interval 1.33, 1.81). Participants' reports of gaps in care coordination were associated with an increased odds of preventable adverse outcomes. Future interventions should leverage patients' observations to detect and resolve gaps in care coordination.

Patterns of Prescription Opioid Use Prior to Self-reported Heroin Initiation.

To determine the association between self-reported heroin initiation and patterns of prescription opioid use. Using linked Oregon Medicaid, prescription drug monitoring program, and Treatment Episodes Data Set data, we conducted a case-control study of individuals reporting heroin initiation between 2015 and 2017 during treatment intake. Prescription drug monitoring program data provided prescription opioid use patterns, including long-term prescription opioid therapy, in the year before self-reported heroin initiation. Four controls were matched to each case on aggregate prescription opioid use and demographics. About half (49%) of individuals who reported heroin initiation filled an opioid in the year before initiation. Individuals who initiated heroin (n = 306) were more likely to receive prescriptions from multiple prescribers (24% vs 18%, P = 0.007) and pharmacies (12% vs 5%, P < 0.001) compared with matched controls (n = 1224). Long-term opioid therapy (13% vs 14%, P = 0.74) was uncommon and did not differ between groups. Although prescription opioid use commonly preceded self-reported heroin initiation, long-term opioid therapy was not common. Although this study did not find an association between opioid discontinuation and heroin initiation, sample size and follow-up limitations preclude definitive conclusions. Efforts to limit prescription opioids should continue to evaluate for unintended harms.

Association between psychotropic drug use and prescription opioid use among older adults

This study investigated the association between psychotropic drug use and prescription opioid use/high dosage opioid use among older adults. A sample of 203,750 older adults enrolled in Pennsylvania's Pharmaceutical Assistance Contract for the Elderly (PACE) program during 2017 was evaluated for prescription opioid and psychotropic drug usage. High dosage opioid use was defined as using >90 morphine milligram equivalents (MME)/day for ≥90 consecutive days. Overall, 20.7% of enrollees filled opioid prescriptions, of which 1.4% used them at high dosages. Multivariate logistic regression indicated that the odds of prescription opioid use increased with anxiolytic/sedative/hypnotic use and antidepressant use. Moreover, high dosage opioid use was significantly associated with anxiolytic/sedative/hypnotic use, antidepressant use and other factors including being younger, male, white, and married but living separately, and having multiple opioid prescribers. Clinicians should carefully evaluate opioid use among older patients using anxiolytics or antidepressants to minimize risks for adverse consequences of opioids.

Variations in antibiotic prescribing among village doctors in a rural region of Shandong province, China: a cross-sectional analysis of prescriptions

ObjectivesTo assess variation in antibiotic prescribing practices among village doctors in a rural region of Shandong province, China.Design, setting and participantsAlmost all outpatient encounters at village clinics result in a prescription being issued. Prescriptions were collected over a 2.5-year period from 8 primary care village clinics staffed by 24 doctors located around a town in rural Shandong province. A target of 60 prescriptions per clinic per month was sampled from an average total of around 300. Prescriptions were analysed at both aggregate and individual-prescriber levels, with a focus on diagnoses of likely viral acute upper respiratory tract infections (AURIs), defined as International Classification of Diseases, 10th Revision codes J00 and J06.9.Main outcome measuresProportions of prescriptions for AURIs containing (1) at least one antibiotic, (2) multiple antibiotics, (3) at least one parenteral antibiotic; classes and agents of antibiotics prescribed.ResultsIn total, 14 471 prescriptions from 23 prescribers were ultimately included, of which 5833 (40.3%) contained at least 1 antibiotic. Nearly two-thirds 62.5% (3237/5177) of likely viral AURI prescriptions contained an antibiotic, accounting for 55.5% (3237/5833) of all antibiotic-containing prescriptions. For AURIs, there was wide variation at the individual level in antibiotic prescribing rates (33.1%–88.0%), as well multiple antibiotic prescribing rates (1.3%–60.2%) and parenteral antibiotic prescribing rates (3.2%–62.1%). Each village doctor prescribed between 11 and 21 unique agents for AURIs, including many broad-spectrum antibiotics. Doctors in the highest quartile for antibiotic prescribing rates for AURI also had higher antibiotic prescribing rates than doctors in the lowest quartile for potentially bacterial upper respiratory tract infections (pharyngitis, tonsillitis, laryngopharyngitis; 89.1% vs 72.4%, p=0.002).ConclusionsAll village doctors overused antibiotics for respiratory tract infections. Variations in individual prescriber practices are significant even in a small homogenous setting and should be accounted for when developing targets and interventions to improve antibiotic use.

Dietary supplement use by older adults with chronic venous leg ulcers: A retrospective, descriptive study.

Nearly 70% of older adults in the U.S. report using ≥1 dietary supplements (DSs) daily. While DSs may have health benefits, there is risk for toxicity or harmful drug-supplement interactions if not taken correctly. Older adults with chronic wounds who use DSs are at increased risk of adverse drug-supplement interactions because they usually have comorbidities requiring polypharmacy management. However, no studies have evaluated DS use in this population. The aim of this retrospective pilot study was to describe DS use by a sample of older adults (n = 40) with chronic venous leg ulcers (CVLUs) who participated in a clinical trial testing the effects of fish oil supplementation on wound healing. At baseline, study personnel assisted all participants in completing an electronic questionnaire about DS use. Descriptive statistics were used to characterize the data. Twenty-five of the 40 participants (62.5%) reported taking ≥1 DS daily. On average, DS users were 65.16 years (SD = 8.51) and the majority were men (64.0%), white (68.0%), and had at least some college education (72.0%). Fifteen (60.0%) reported taking 1-2 DSs/day, and 10 (40.0%) reported taking ≥3/day. The most frequently reported DSs used were multivitamin/mineral complex (60.0%), vitamin D (36.0%), vitamin B complex (28.0%) and calcium (28.0%). Reasons for using DSs were to maintain or improve health (44.0%), improve bone density (12%), and boost the immune system (12%). Supplement users reported consuming an average of 9.12 (SD = 6.46) prescription drugs daily and 21 (84.0%) reported ≥3 chronic health conditions. In summary, DS use in this sample of chronic wound patients was high. Moreover, DS users reported using multiple prescription drugs (2-23/day) concomitantly with DSs. While older adults with CVLUs may benefit from targeted DS therapy, monitoring their DS use to reduce risk for adverse drug-supplement interactions is best practice.

PNS111 HEALTH PLAN PERFORMANCE ON HIGH-RISK MEDICATION USE AMONG MEDICARE PART D BENEFICIARIES: IMPACT OF RISK ADJUSTMENT

Current Medicare health plan performance measures do not consider variations of patient characteristics within health plans, potentially leading to incorrect performance evaluations. This study examined the relationship between patient characteristics and high-risk medication (HRM) use and the impact of risk adjustment on HRM use measures among Medicare Advantage Prescription Drug Plan (MA-PD) and stand-alone Prescription Drug Plan (PDP) beneficiaries. This retrospective cross-sectional study used a 5% national sample of 2013 Medicare claims. Two groups of beneficiaries aged ≥65 years, continuously enrolled in MA-PD or PDP, and with ≥2 prescriptions for the same HRM (defined by Pharmacy Quality Alliance) were identified. First, we calculated unadjusted performance scores as a proportion of HRM users in each health plan. Second, we identified HRM use risk factors using multivariable logistic regression models for MA-PD and PDP. Third, we developed risk-adjustment scores using generalized linear mixed models to adjust for identified risk factors in specific plans within MA-PDs and PDPs. Agreement between unadjusted and adjusted scores was evaluated using Cohen’s kappa to demonstrate the effect of risk adjustment. This study included 520,019 MA-PD and 881,264 PDP beneficiaries (mean age=74.7±7.3 versus 75.6±7.8 years; females=61% versus 64%; white=81.7% versus 85.5%) enrolled in 474 MA-PD and 60 PDP contracts. In adjusted analyses, HRM users in MA-PDs were more likely to be younger (OR=0.981, 95%CI=0.980-0.983); women (OR=1.545, 95%CI=1.514-1.576); eligible for low-income subsidy (OR=1.086, 95%CI=1.057-1.115); disabled (OR=1.380, 95%CI=1.342-1.420); seeing multiple prescribers (OR=1.076, 95%CI=1.072-1.081); using multiple pharmacies (OR=1.092, 95%CI=1.083-1.102); and higher average modified RxRisk-V index (OR=1.176, 95%CI=1.171-1.181) than non-HRM users. PDP results were similar. Unadjusted scores had low levels of agreement (Cohen’s kappa <0.7) with risk-adjusted scores. This study suggests risk adjustment influences health plan performance evaluation. Thus, risk adjustment of HRM performance is recommended to ensure health plans are not penalized due to their beneficiaries’ characteristics.

Multiple opioid prescribers: A genuine quest for treatment rather than aberrant behaviour. A two-decade population-based study

BackgroundAccessing multiple prescribers for opioid prescription, referred to as doctor-shopping, is associated with an increased risk of opioid overdose and fatalities. AimThe primary aim of this study was to assess the probability of accessing multiple prescribers among patients dispensed prescription opioids. MethodA retrospective population-based study using the Monitoring of Drugs of Dependence system of the Medicines Monitoring Unit (MMU) of Queensland Health, Australia. We assessed the odds of accessing multiple prescribers across both -short-term (≤1 month, 2–3 months) and longer-term (4–6 months and ≥7 months). We examined the relationship between multiple doctor visits, the dispensed dose of opioid and patient’s residential socioeconomic status (SES). ResultCompared to those dispensed opioid prescriptions for ≥7–12 months, those dispensed opioids for ≤1 month were more likely to have visited ≥3 prescribers (adjusted odds ratio (aOR)) 4.06, 95% CI 4.01, 4.10, while for 2–3 months and 4–6 months the odds were aOR 2.36, 95% CI 2.33, 2.39 and aOR 1.79, 95% CI 1.74, 1.79 respectively.Patients dispensed opioid doses of ≥100 oral morphine milligram equivalent per day (MME/day) were more likely to obtain prescriptions from ≥3 prescribers compare to those receiving a dose of <20MME/day (aOR 1.90; 95% CI 1.87, 1.94).The probability of obtaining opioid prescriptions from multiple prescribers increased as the socioeconomic status decreased: aOR 1.41; 95% CI 1.38, 1.44 for lowest SES compared to the highest SES. ConclusionPatients were more than four time likely to be dispensed opioid prescriptions from multiple prescribers within the first 30 days of initiating opioid treatment, possibly as part of multidisciplinary referral post-hospital discharge. High dose opioid and low SES was associated with higher probability of accessing multiple prescribers.

Impact of Automated Targeted Medication Review Electronic Alerts to Reduce Potentially Inappropriate Medication Prescribing Among Medicare Enrolled Patients With Dementia.

Background:Finding ways to reduce prescribing of potentially inappropriate medications (PIMs) among patients with dementia is necessary. To evaluate an automated targeted medication review (TMR) service to reduce PIM prescribing among patients with dementia. This was a retrospective observational analysis of patients in a Medication Therapy Management (MTM) program for year 2017. Patients included if Medicare enrolled, MTM eligible, had dementia, and with PIM prescribing. Descriptive statistics described reduced PIM prescribing. Odds ratios (ORs) assessed prescriber relationship with PIM prescribing. Regression evaluated relationship between patient characteristics and discontinued PIMs. A total of 33 696 TMRs were triggered for 17 933 patients. Four months later, 11 608 TMRs led to a discontinued PIM among 8002 patients. Medications with the largest discontinuations were antihistamines (56%), muscle relaxants (53%), antiemetics (53%), and typical antipsychotics (40%). Physician primary care providers (PCPs) were more likely than nonphysician PCPs (OR = 4.54; 95% CI = 4.15-4.97; P < 0.001), psychiatrists (OR = 1.64; 95%CI = 1.44-1.86; P < 0.001), and neurologists (OR = 4.48; 95% CI = 4.07-4.93; P < 0.001) to prescribe medications to treat dementia and PIMs. Regression showed that younger age, female gender, higher poverty level, and a greater number of pharmacies, medications, and prescribers were associated with discontinued PIMs. Conclusions and Relevance: TMRs were effective in reducing PIM prescribing. Younger patients, individuals living in higher poverty levels, and patients with multiple prescribers or pharmacies may benefit most from this service. TMRs in primary care offices may reduce PIM prescribing.