Outpatient Medication Use Research Articles

Management of potentially inappropriate medication use among older adult’s patients in primary care settings: description of an interventional prospective non-randomized study

BackgroundThe management of inappropriate medication use in older patients suffering from multimorbidity and polymedication is a major healthcare challenge. In a primary care setting, a medication review is an effective tool through which a pharmacist can collaborate with a practitioner to detect inappropriate drug use.AimThis project described the implementation of a systematic process for the management of potentially inappropriate medication use among Lebanese older adults. Its aim was to involve pharmacists in geriatric care and to suggest treatment optimization through the analysis of prescriptions using explicit and implicit criteria.MethodThis study evaluated the medications of patients over 65 years taking a minimum of five chronic medications a day in different regions of Lebanon. Descriptive statistics for all the included variables using mean and standard deviation (Mean (SD)) for continuous variables and frequency and percentage (n, (%)) for multinomial variables were then performed.ResultsA total of 850 patients (50.7% women, 28.6% frail, 75.7 (8.01) mean age (SD)) were included in this study. The mean number of drugs per prescription was 7.10 (2.45). Roughly 88% of patients (n = 748) had at least one potentially inappropriate drug prescription: 66.4% and 64.4% of the patients had at least 1 drug with an unfavorable benefit-to-risk ratio according to Beers and EU(7)-PIM respectively. Nearly 50.4% of patients took at least one medication with no indication. The pharmacists recommended discontinuing medication for 76.5% of the cases of drug related problems. 26.6% of the overall proposed interventions were implemented.DiscussionThe rate of potentially inappropriate drug prescribing (PIDP) (88%) was higher than the rates previously reported in Europe, US, and Canada. It was also higher than studies conducted in Lebanon where it varied from 22.4 to 80% depending on the explicit criteria used, the settings, and the medical conditions of the patients. We used both implicit and explicit criteria with five different lists to improve the detection of all types of inappropriate medication use since Lebanon obtains drugs from many different sources. Another potential source for variation is the lack of a standardized process for the assessment of outpatient medication use in the elderly.ConclusionThe prevalence PIDP detected in the sample was higher than the percentages reported in previous literature. Systematic review of prescriptions has the capacity to identify and resolve pharmaceutical care issues thus improving geriatric care.

High-Throughput Computing to Automate Population-Based Studies to Detect the 30-Day Risk of Adverse Outcomes After New Outpatient Medication Use in Older Adults with Chronic Kidney Disease: A Clinical Research Protocol.

Safety issues are detected in about one third of prescription drugs in the years following regulatory agency approval. Older adults, especially those with chronic kidney disease, are at particular risk of adverse reactions to prescription drugs. This protocol describes a new approach that may identify credible drug-safety signals more efficiently using administrative health care data. To use high-throughput computing and automation to conduct 700+ drug-safety cohort studies in older adults in Ontario, Canada. Each study will compare 74 acute (30-day) outcomes in patients who start a new prescription drug (new users) to a group of nonusers with similar baseline health characteristics. Risks will be assessed within strata of baseline kidney function. The studies will be population-based, new-user cohort studies conducted using linked administrative health care databases in Ontario, Canada (January 1, 2008, to March 1, 2020). The source population for these studies will be residents of Ontario aged 66 years or older who filled at least one outpatient prescription through the Ontario Drug Benefit (ODB) program during the study period (all residents have universal health care, and those aged 65+ have universal prescription drug coverage through the ODB). We identified 3.2 million older adults in the source population during the study period and built 700+ initial medication cohorts, each containing mutually exclusive groups of new users and nonusers. Nonusers were randomly assigned cohort entry dates that followed the same distribution of prescription start dates as new users. Eligibility criteria included a baseline estimated glomerular filtration rate (eGFR) measurement within 12 months before the cohort entry date (median time was 71 days before cohort entry in the new user group), no prior receipt of maintenance dialysis or a kidney transplant, and no prior prescriptions for drugs in the same subclass as the study drug. New users and nonusers will be balanced on ~400 baseline health characteristics using inverse probability of treatment weighting on propensity scores within 3 strata of baseline eGFR: ≥60, 45 to <60, <45 mL/min per 1.73 m2. We will compare new user and nonuser groups on 74 clinically relevant outcomes (17 composites and 57 individual outcomes) in the 30 days after cohort entry. We used a prespecified approach to identify these 74 outcomes. In each cohort, we will obtain eGFR-stratum-specific weighted risk ratios and risk differences using modified Poisson regression and binomial regression, respectively. Additive and multiplicative interaction by eGFR category will be examined. Drug-outcome associations that meet prespecified criteria (identified signals) will be further examined in additional analyses (including survival, negative-control exposure, and E-value analyses) and visualizations. The initial medication cohorts had a median of 6120 new users per cohort (interquartile range: 1469-38 839) and a median of 1 088 301 nonusers (interquartile range: 751 697-1 267 009). Medications with the largest number of new users were amoxicillin trihydrate (n = 1 000 032), cephalexin (n = 571 566), prescription acetaminophen (n = 571 563), and ciprofloxacin (n = 504,374); 19% to 29% of new users in these cohorts had an eGFR <60 mL/min per 1.73 m2. Despite our use of robust techniques to balance baseline indicators and to control for confounding by indication, residual confounding will remain a possibility. Only acute (30-day) outcomes will be examined. Our data sources do not include nonprescription (over-the-counter) drugs or drugs prescribed in hospitals and do not include outpatient prescription drug use in children or adults <65 years. This accelerated approach to conducting postmarket drug-safety studies has the potential to more efficiently detect drug-safety signals in a vulnerable population. The results of this protocol may ultimately help improve medication safety.

Recent trends in incidence, survival and treatment of multiple myeloma in Finland – a nationwide cohort study

This study aimed to determine the incidence and prevalence of multiple myeloma (MM) in Finland in 2015–2019, to characterize adult patients newly diagnosed with MM, and to follow-up their overall survival (OS) and treatment patterns until the end of 2020. We sourced the data on inpatient and outpatient diagnoses, outpatient medication use, and date of death from comprehensive, nationwide registers. We identified 2037 incident patients with MM in 2015–2019. On average, the annual crude incidence was 8.8 and the age-standardized incidence (World Standard Population) was 3.3 per 100,000. The crude prevalence at the end of 2019 was 32.7 cases per 100,000 inhabitants ≥ 18 years of age. Median age of the patients at first diagnosis (index date) was 71 years, and 48% were female, the median follow-up being 2.4 years. The median OS was estimated at 4.5 years. The proportion of the patients receiving autologous stem cell transplantation (ASCT) within one year since the index date was 24%, with little variation across study years. Conversely, the proportion of all patients receiving lenalidomide within one year since the index date increased from 27 to 48% overall, and from 39 to 81% among ASCT recipients. The estimated median relapse-free survival after ASCT was 2.9 years. Information on in-hospital MM medication administrations was available for a subset of the study cohort. In this subset, 85.8% of the patients received immunomodulatory drugs and/or proteasome inhibitors within the first year after the index date.

Medication Safety Events After Acute Myocardial Infarction Among Veterans Treated at VA Versus Non-VA Hospitals.

Fragmentation of health care across systems can contribute to mistakes in prescribing and filling medications among patients treated for myocardial infarction (MI). We sought to compare omissions, duplications, and delays in outpatient medications used for secondary prevention among veterans treated for MI at Veterans Affairs (VA) versus non-VA hospitals. We utilized national VA and Centers for Medicare and Medicaid Services data (2012-2018) to identify veterans 65 years or older hospitalized for MI and measured the use of outpatient medications for secondary prevention in the 30 days after MI among those treated at VA versus non-VA hospitals. A total of 118,456 veterans experiencing MI were included; of which 102,209 were hospitalized at non-VA hospitals. An omission in any medication class occurred more frequently among veterans treated at non-VA versus VA hospitals (82.8% vs 67.8%, P < 0.001). In multivariable modeling, the odds of omissions in any medication class were higher among those treated at non-VA versus VA hospitals (odds ratio: 3.04; 95% CI: 2.88-3.20). Duplications occurred more frequently in veterans treated at non-VA versus VA hospitals: 1.9% versus 1.6% had 1 or more for non-VA versus VA hospitals ( P < 0.001). Veterans treated at non-VA hospitals were more likely to have delays of 3 days or more in prescription fills after hospital discharge (88.4% vs 70.6% across all classes, P < 0.001). Omissions, duplications, and delays in outpatient prescribing of secondary prevention medications were more common among 118,456 veterans treated at non-VA versus VA hospitals for MI. Interventions aimed at improving care transitions and optimizing medication use among veterans treated at non-VA hospitals should be implemented.

Short and long-term inequity in outpatient medical use by the type of medical institutions in Korea

Abstract Background Many countries agree with the horizontal equity that medical resources should be allocated according to medical needs, regardless of income. Although the short-term equity index calculated through cross-sectional data doesn't reflect the dynamics of individual income and medical use, it can be supplemented by the long-term equity index using panel data. Koreans tend to choose expensive but highly specialized services without considering their medical needs because they are free to choose service providers. This study aims to empirically examine how the patterns of outpatient medical use that are not based on medical needs differ in terms of short- and long-term equity for each type of medical institution. Methods Using Korea Health Panel Survey(2014-2018), the equity of outpatient medical use(number of visits, medical expenses) of 10,244 people was measured by type of medical institution (tertiary general hospital, general hospital, hospital, clinic, and dentist). Wagstaff&amp;van Doorslaer(2000)’s tool and Jones &amp; Lopez-Nicolas(2004)’s tool were used to calculate the short and long-term horizontal equity index(HI), and mobility index(MI) to compare short and long-term inequity. Results In tertiary general hospitals and dentists, there were short and long-term pro-rich inequalities(HI &amp;gt; 0, p &amp;lt; 0.05). As a result of comparison, long-term inequality was greater in the number of visits (MI &amp;lt; 0), while inequality was easing in the long-term in medical expenses(MI &amp;gt; 0) in tertiary general hospitals. In dentists, long-term inequality was less than short-term inequality in both the number of visits and medical expenses (MI &amp;gt; 0). Conclusions The short-term equity index is likely to underestimate or overestimate inequity in our society, so a long-term perspective is needed. Inequality patterns for each type of medical institution should be considered in healthcare reforms for fair distribution of medical resources. Key messages • Short-term equity index differs from the long-term equity index in outpatient medical use. • The pattern of short and long-term equity indices may differ by type of medical institutions.

Letter to the Editor-Response to "A Qualitative Analysis of Outpatient Medication Use in Community Settings: Observed Safety Vulnerabilities and Recommendations for Improved Patient Safety".

Letter to the Editor-Response to "A Qualitative Analysis of Outpatient Medication Use in Community Settings: Observed Safety Vulnerabilities and Recommendations for Improved Patient Safety".

Bleeding risk and healthcare resource utilisation in elderly patients treated with edoxaban or vitamin K antagonists for atrial fibrillation in Italy

Abstract Funding Acknowledgements Type of funding sources: Other. Main funding source(s): Daiichi Sankyo Europe GmbH Background Direct oral anticoagulants (DOACs) have been shown to be non-inferior to vitamin K antagonists (VKA) regarding both efficacy and safety outcomes in patients with atrial fibrillation (AF). However, elderly are underrepresented in the underlying clinical trials. Purpose The aim of this study was to compare risks of major bleeding events and compare healthcare resource utilization (HRU) between AF patients treated with edoxaban or VKA in elderly. Methods A cohort study was conducted using claims databases of Caserta and Palermo Local Heath Units in Italy. AF patients starting use of edoxaban or VKA between August 1st, 2016 and December 31st, 2018 were included. Date of the first dispensing was defined as the index date. The study population was matched based on a propensity score based on factors associated with the outcome. We restricted to patients aged ≥65, ≥1 year database history, and no use of the index drug in the year before index date. Incidence rates of bleeding outcomes and rates of HRU were assessed per 1,000 and 100 person-years follow-up (PY), respectively. Cox regression analyses to adjust for baseline covariates were used for comparisons of incidence rates of bleeding outcomes among all edoxaban and VKA users. Poisson regression analyses were used for comparisons of rates of HRU among all edoxaban and VKA users. Both analyses were adjusted for age. Sex, region and year of index date were considered for the adjusted models as well, using a backward stepwise approach to select eligible variables. Results 1,317 edoxaban users and 2,924 VKA users were included in the matched population. Mean age was 79 in both treatments groups, and 43% of the edoxaban users and 45% of the VKA users was male. Bleeding risks were significantly lower among edoxaban users compared to VKA users aged ≥65 (adjusted HR 0.39 (95% CI 0.19-0.83)) and among patients aged ≥75 (adjusted HR 0.37 (95% CI 0.16-0.86)). Among patients aged ≥65, edoxaban users were significantly less often hospitalised (RR 0.56 (95% CI 0.46-0.68)) and the total number of hospitalised days were also significant lower (RR 0.58 (95% CI 0.42-0.80)) compared to VKA users. Among patients aged ≥75, similar results were observed for the number of hospitalisations. Edoxaban users had significant less out-patient visits compared to VKA users (among patients aged ≥65 the RR was 0.44 (95% CI 0.39-0.50) and among patients ≥75 this was 0.40 (95% CI 0.35-0.47). Use of out-patient medication use was significantly lower among edoxaban users compared to VKA users among patients aged ≥65 (adjusted RR 0.91 (95% CI 0.88-0.95)) as well as among patients aged ≥75 (adjusted RR 0.91 (95% CI 0.87-0.95)). Conclusion Study results show a decreased bleeding risk of edoxaban compared to VKA in both age groups of patients with AF. Hospital based HRU has shown to be lower among edoxaban users compared to VKA users in both age groups. Out-patient HRU was also lower among edoxaban users.

Central Nervous System Depressants and Risk of Hospitalization due to Community-Acquired Pneumonia in very Old Patients.

Central Nervous System (CNS) depressants like antipsychotics, opioids, benzodiazepines and zolpidem are frequently used by patients of a wide range of ages. Uncertainty remains about their effect in very old adults (>80 years old) and their potential for pharmacodynamic and pharmacokinetic drug-drug interactions in this population. To assess if the use of CNS depressants is associated with a higher risk of hospitalization due to community-acquired pneumonia (CAP) in very old patients. In this prospective study, 362 patients over 80 years of age who had been consequently admitted to the general ward of a teaching hospital were examined. Each patient was assessed, by our pharmacovigilance team within 24 hours of admission, to identify outpatient medication use and potential drug-drug interactions. The overall use of CNS depressants as a group was not associated with a higher risk of admission due to CAP in very old patients (55% vs. 49%; OR=1.28 [0.76-2.16], p=0.34). However, the use of antipsychotics was associated with a higher rate of admissions due to CAP in this population (OR=1.98 [1.10-3.57], p=0.02). No association was seen between opioids (p=0.27), zolpidem (p=0.83), or benzodiazepines (p=0.15) and the rate of admissions due to CAP in these patients. Moreover, pharmacodynamic or pharmacokinetic interactions leading to CNS depression were equally found in patients admitted for CAP and those admitted for other reasons. The use of antipsychotics in very old adults was associated with an increased risk of hospital admission due to CAP. This suggests that the use of these medications in this population should be done with caution. No association was observed with opioids, benzodiazepines and zolpidem with the latter outcome.

Electronic Health Record-Based Strategy to Promote Medication Adherence Among Patients With Diabetes: Longitudinal Observational Study.

BackgroundPoor medication adherence is common; however, few mechanisms exist in clinical practice to monitor how patients take medications in outpatient settings.ObjectiveThis study aimed to pilot test the Electronic Medication Complete Communication (EMC2) strategy, a low-cost, sustainable approach that uses functionalities within the electronic health record to promote outpatient medication adherence and safety.MethodsThe EMC2 strategy was implemented in 2 academic practices for 14 higher-risk diabetes medications. The strategy included: (1) clinical decision support alerts to prompt provider counseling on medication risks, (2) low-literacy medication summaries for patients, (3) a portal-based questionnaire to monitor outpatient medication use, and (4) clinical outreach for identified concerns. We recruited adult patients with diabetes who were prescribed a higher-risk diabetes medication. Participants completed baseline and 2-week interviews to assess receipt of, and satisfaction with, intervention components.ResultsA total of 100 patients were enrolled; 90 completed the 2-week interview. Patients were racially diverse, 30.0% (30/100) had a high school education or less, and 40.0% (40/100) had limited literacy skills. About a quarter (28/100) did not have a portal account; socioeconomic disparities were noted in account ownership by income and education. Among patients with a portal account, 58% (42/72) completed the questionnaire; 21 of the 42 patients reported concerns warranting clinical follow-up. Of these, 17 were contacted by the clinic or had their issue resolved within 24 hours. Most patients (33/38, 89%) who completed the portal questionnaire and follow-up interview reported high levels of satisfaction (score of 8 or greater on a scale of 1-10).ConclusionsFindings suggest that the EMC2 strategy can be reliably implemented and delivered to patients, with high levels of satisfaction. Disparities in portal use may restrict intervention reach. Although the EMC2 strategy can be implemented with minimal impact on clinic workflow, future trials are needed to evaluate its effectiveness to promote adherence and safety.

A Qualitative Analysis of Outpatient Medication Use in Community Settings: Observed Safety Vulnerabilities and Recommendations for Improved Patient Safety.

The aim of the study was to analyze diverse patients' experiences throughout the medication use process to inform the development of overarching interventions that support safe medication use in community settings. Using a qualitative observational approach, we conducted approximately 18 hours of direct observation of the medication use process across multiple settings for a sample of vulnerable, high-risk patients. Observers recorded detailed field notes during the observations. To enrich the observational findings, we also conducted six semistructured interviews with medication safety experts representing a diversity of perspectives. Barriers and facilitators to safe medication use were identified based on inductive coding of the data. A variety of safety vulnerabilities plague all stages of the medication use process and many of the well-established evidence-based interventions aimed at improving the safety of medication use at key stages of the process have not been widely implemented in community settings observed in this study. Key safety vulnerabilities identified include: limited English proficiency, low health literacy, lack of clinician continuity, incomplete medication reconciliation and counseling, unsafe medication storage and disposal habits, and conflicting healthcare agendas with caregivers. Our findings underscore a need for overarching, comprehensive interventions that span the entire process of medication use, including integrated communication systems between clinicians, pharmacies, and patients, and a "patient navigator" program that assists patients in navigating the entire medication-taking process. Collective ownership of the medication management system and mutual motivation for devising collaborative solutions is needed among key sectors.

Medication Use among Veterans across Health Care Systems.

Dual healthcare system use can create gaps and fragments of information for patient care. The Department of Veteran Affairs is implementing a health information exchange (HIE) program called the Virtual Lifetime Electronic Record (VLER), which allows providers to access and share information across healthcare systems. HIE has the potential to improve the safety of medication use. However, data regarding the pattern of outpatient medication use across systems of care is largely unknown. Therefore, the objective of this study is to describe the prevalence of medication dispensing across VA and non-VA health care systems among a cohort Veteran population. This study included all Veterans who had two outpatient visits or one inpatient visit at the Indianapolis VA during a 1-year period prior to VLER enrollment. Source of medication data was assessed at the subject level, and categorized as VA, INPC (non-VA), or both. The primary target was identification of sources for medication data. Then, we compared the mean number of prescriptions, as well as overall and pairwise differences in medication dispensing. Out of 52,444 Veterans, 17.4% of subjects had medication data available in a regional HIE. On average, 40 prescriptions per year were prescribed for Veterans who used both sources compared to 29 prescriptions per year from VA only and 25 prescriptions per year from INPC only sources. The annualized prescription rate of Veterans in the dual use group was 36% higher than those who had only VA data available and 61% higher than those who had only INPC data available. Our data demonstrated that 17.4% of subjects had medication use identified from non-VA sources, including prescriptions for antibiotics, antineoplastics, and anticoagulants. These data support the need for HIE programs to improve coordination of information, with the potential to reduce adverse medication interactions and improve medication safety.

Outpatient Medication Use in Chinese Geriatric Patients Admitted for Falls: A Case-Control Study at an Acute Hospital in Hong Kong.

The study objective was to investigate the association of polypharmacy and medications with patient falls resulting in hip fractures among community-living geriatric patients. A case-control study was conducted at an acute public hospital in Hong Kong. The study population was community-living Chinese patients aged 65 years and above who were admitted for falls resulting in hip fractures during an 18-month study period. Each of these patients was matched to a control patient with the same age and sex, but without falls and fractures. Data were collected from electronic patient record. Data of 170 cases and 170 controls were eventually collected. The following variables associated with increased risk of falls resulting in hip fractures remained statistically significant after multivariate logistic regression, including benign prostatic hyperplasia [odds ratio (OR) = 2.654; 95% confidence interval (CI), 1.105-6.378; P = 0.029], first-generation antihistamines (OR = 3.176; 95% CI, 1.044-9.664; P = 0.042), antiparkinson medications (OR = 3.754; 95% CI, 1.158-12.169; P = 0.027), osteoporosis (OR = 3.159; 95% CI, 1.167-8.552; P = 0.024), and use of walking aids (OR = 2.543; 95% CI, 1.544-4.188; P < 0.001). In conclusion, this study identified various medications and comorbidities, rather than polypharmacy based on the number of medications, as predictors associated with increased risk of falls resulting in hip fractures for local geriatric patients. The findings provided insights into the potential medication-related fall prevention strategies, including clinical medication review, adverse drug event monitoring, and drug optimization.

PD26-12 USE OF MEDICAL THERAPY AND SUCCESS OF LASER SURGERY AND TURP FOR BPH

You have accessJournal of UrologyBenign Prostatic Hyperplasia: Surgical Therapy & New Technology I1 Apr 2014PD26-12 USE OF MEDICAL THERAPY AND SUCCESS OF LASER SURGERY AND TURP FOR BPH Seth Strope, Joel Vetter, Sean Elliott, Gerald Andriole, and Margaret Olsen Seth StropeSeth Strope More articles by this author , Joel VetterJoel Vetter More articles by this author , Sean ElliottSean Elliott More articles by this author , Gerald AndrioleGerald Andriole More articles by this author , and Margaret OlsenMargaret Olsen More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2014.02.2099AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES For men with LUTS, surgical intervention provides excellent symptom management. However, utilization of medical therapy around surgery is not well characterized. We assessed the pre- and post-operative utilization of BPH related medications among surgically treated men. METHODS Using the Truven Health Analytics MarketScan® Commercial Claims Database, a database of commercially insured patients, we defined a cohort of men, < 65 years of age, who had surgical therapy for LUTS with either TURP or laser procedures from 2007 through 2009. We assessed outpatient medication use (5-ARIs, alpha blockers, anticholinergics) for one year prior to surgery through 4 months after surgery. Types of medications used were compared before and 4 months after surgery by chi-square testing. We then compared TURP and laser procedures for the proportion of patients who failed surgery (defined as use of medication at 4 months after the index procedure or repeat surgical procedure within four months after the index procedure). RESULTS We identified 6500 patients who were treated with either TURP (3404 patients) or a laser procedure (3096 patients) for BPH. We found no difference in the proportion of patients using BPH medication at the time of surgery (46% TURP, 47% laser, p = 0.38). After surgery, TURP patients were significantly less likely to be on medical therapy (16% versus 20%; p < 0.001). While most patients were on no medication by 4 months post surgery, use of antispasmodic medication increased among both laser and TURP patients (Figure). By 4 months after surgery, patients who received laser therapy were significantly more likely to have had a failure event than TURP patients (21% failures laser; 16% failures TURP; p = 0.001). CONCLUSIONS Most patients who receive surgical therapy for BPH are not current users of medical therapy for LUTS. However, a significant proportion of patients are using medical therapy 4 months after surgical intervention, with laser therapy associated with increased risk of such failure. These results suggest men need to be counseled on the possibility of continued or new medical therapy after surgical intervention for LUTS. © 2014FiguresReferencesRelatedDetails Volume 191Issue 4SApril 2014Page: e763-e764 Advertisement Copyright & Permissions© 2014MetricsAuthor Information Seth Strope More articles by this author Joel Vetter More articles by this author Sean Elliott More articles by this author Gerald Andriole More articles by this author Margaret Olsen More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Effectiveness of Standardized Combination Therapy for Migraine Treatment in the Pediatric Emergency Department

To compare outcomes of pediatric migraine patients treated in an emergency department (ED) before and after implementation of a standardized combination intravenous therapy regimen aimed toward improving and standardizing abortive migraine therapy. In a pediatric ED, migraines represent 8-18% of all headache visits. Despite this large number, no standard treatment for acute migraine therapy currently exists. The study utilized a retrospective chart review of patients seeking acute migraine treatment at a tertiary care, pediatric ED from August 2006 to March 2010. Inclusion criteria were pediatric migraine patients as defined by International Headache Society guidelines. The comparison population received various migraine therapies based on attending practice preference. After October 2008, patients received standardized intravenous combination therapy involving a normal saline fluid bolus, ketorolac, prochlorperazine, and diphenhydramine. Occasionally, metoclopramide was substituted during prochlorperazine shortages. Reduction in headache pain score was the primary outcome. Secondary outcome measures included length of ED stay, hospital admission rate, and ED readmission rate within 48 hours. The study yielded 87 patients who received standardized combination therapy and 165 comparison patients. No significant difference in patient characteristics existed when evaluating patient demographics, outpatient medication use, and initial headache pain score. When compared with the non-standardized therapy population, the combination therapy patients revealed significant reductions in pain score (decrease of 5.3 vs. 6.9, difference -1.6, 95% confidence interval -2.2 to -0.8, P < .001), length of ED stay (5.3 vs. 4.4 hours, difference 0.9, 95% confidence interval 0.2-1.6, P = .008), and hospital admission rate (32% vs. 3%, P < .001) without changes in ED return rate (7% vs. 2%, P = .148). Standardized combination therapy is effective for acute pediatric migraine therapy in the ED by significantly reducing headache pain scores, length of ED stay, and hospital admission rates.

Impact of oncology drug shortages on patient treatment.

6114 Background: Cancer drug shortages increased considerably over the past 5 years, but quantitative analyses of the scope and effects are limited. We assessed the effects of drug shortages on outpatient medication use in a single New York City university hospital. Methods: We examined pharmacy records for drug shortages, defined by the ASHP as supply issues that affect “how the pharmacy prepares or dispenses a drug product or influences patient care when prescribers must use an alternative agent.” We examined outpatient records for all cancer patients treated with infusional antineoplastic and/or supportive medications from 4/2010-9/2010 and from 4/2011-9/2011, and performed subgroup analysis on Aug/Sept 2011, the peak of medication availability problems at our hospital. We compared proportions of patients treated with specific medications in 2010 and 2011 with Pearson’s chi-square test. Results: Twelve medications were in shortage during the study period in 2010 and 22 in 2011. Between 4/1/10 and 9/30/10, 335 cancer patients were treated, and 379 patients were treated between 4/1/11 and 9/30/11. Median patient age was 60 years. Cancer site of origin was comparable between years: breast (40%), GI (15%), lymphoma (10%), GU (8%), and lung (7%). Drugs considered in shortage were used for 170 (50.8%) patients in 2010 and 241 (63.6%) patients in 2011 (p=0.0005). Of 235 patients treated in Aug/Sept 2011, there were 23 (9.8%) documented therapy changes due to shortages, compared with 0 changes among 211 patients treated in Aug/Sept 2010 (p&lt;0.0001). Among patients treated in Aug/Sept 2010 24 (11.4%) patients received paclitaxel and 19 (9.0%) received docetaxel. Among patients treated in Aug/Sept 2011, 11 (4.7%) received paclitaxel and 38 received docetaxel (16.2%), a 69% decrease for paclitaxel and 80% increase for docetaxel from 1 year prior (p=0.009, and p=0.024, respectively). The estimated cost of a single treatment with paclitaxel for 1 patient with BSA 1.75 was $47.59 versus $858.39 for docetaxel, a 1704% increase. Conclusions: Oncology drug shortages affected the majority of patients in our center and increased at an alarming rate. Drug shortages have substantial economic costs and mandate treatment changes that may affect efficacy and toxicity.

Post-marketing Surveillance of Methadone and Buprenorphine in the United States

There have been recent increases in the use of methadone and buprenorphine in the United States. Methadone is increasingly being used for pain management, and buprenorphine use has expanded to include treatment for opioid addiction, leading to exposures of these drugs in new populations. There is a debate about the relative safety of these two drugs in routine outpatient medical use. Data from the Researched Abuse, Diversion and Addiction-Related Surveillance (RADARS) System Programs were used to analyze rates of abuse, misuse, and diversion using the Drug Diversion, Key Informant, Poison Center and Opioid Treatment Programs, 2003-2007. National rate and rate ratios were calculated using population and person-time exposed denominators. Detailed data are presented on severity of medical outcome and drug formulations. Between 2003 and 2007, there were steady increases in the rates of abuse, misuse, and diversion of both methadone and buprenorphine. Rate ratios (per 100,000 population per quarter) of abuse, misuse, and diversion were consistently higher for methadone than buprenorphine. RADARS System poison centers received 7,476 calls for methadone and 1,117 calls for buprenorphine. After accounting for availability, there were higher rates of calls for methadone misuse, abuse, and diversion than buprenorphine in three of the four programs. The numbers of exposures requiring medical attention correspond to 46.8% and 25.8% of all calls, for methadone and buprenorphine, respectively. The most commonly diverted form of methadone was solid oral tablets (which are typically dispensed at pharmacies, not at opioid treatment programs), comprising 73% of cases. Buprenorphine appears to have a better safety profile than methadone during routine outpatient medical use. However, both medications have roles in the treatment of pain and opioid addiction, and further research into their respective benefits and risks should be conducted.

Rethinking the Epidemiology of Acute Myocardial Infarction

During the previous decade, many strategies for preventing acute myocardial infarction found to be efficacious in randomized controlled trials have been adopted by physicians in the community. Although evaluations of quality improvement typically focus on process measures at the hospital, practice, or clinician level, assessment of improvements in health outcomes remains the true test for the successful translation of evidence into practice. We performed a review of the current literature examining trends in the incidence of myocardial infarction in communities. We focused specifically on the group of population-based studies that have examined trends in myocardial infarction incidence. Few population-based studies have examined recent temporal trends in the incidence of myocardial infarction, overall and by type. Existing studies have been largely limited by modest sample sizes, limited diversity within the study populations, the use of composite end points that combine disparate outcomes, and the inability to characterize the effect of long-term outpatient medication use on observed trends in incidence and severity of myocardial infarction. More contemporary assessments of community-wide changes in the epidemiology of myocardial infarction are needed to help assess the effectiveness of primary prevention and to identify areas for potential improvement.

Reducing medication errors, comparative effectiveness, and glucocorticosteroid dosing

Reducing medication errors Murray et al.1 reported that pharmacist interventions to improve medication use in outpatients with cardiovascular disease decrease the risk of adverse drug events (ADEs) and medication errors. The multiclinic intervention was provided by specially trained pharmacists. Participants were dispensed medications in containers that enabled electronic monitoring of adherence to the prescribed cardiovascular medications and medication information designed for patients with low health literacy. A computer that was integrated into the electronic medical record system was used for monitoring prescription and nonprescription medications, tracking materials provided to patients, and documenting communications with patients, nurses, and physicians. Compared with the control group, the risk of any event was 34% lower in the intervention group (risk ratio 0.66 [95% CI 0.50–0.88]), including a lower risk of ADEs (0.65 [0.47–0.90)], preventable ADEs (0.52 [0.25–1.09]), potential ADEs (0.70 [0.40–1.22]), and medication errors (0.63 [0.40–0.98]). Practice implications. Most studies of medication therapy management focus on the achievement of intended therapeutic and economic outcomes in community-based ambulatory care. This study showed that the risk of ADEs, especially preventable events, and medication errors was reduced substantially by specially trained pharmacists. Drug misadventures, including ADEs and medication errors, add to the overall cost of medication therapy, and medication use can be improved by pharmacy-based programs.

Effect of a Pharmacist on Adverse Drug Events and Medication Errors in Outpatients With Cardiovascular Disease

Adverse drug events and medication errors are threats to quality care. Inpatient studies suggest that a pharmacist may reduce these events, but outpatient studies have not been forthcoming. We conducted a pooled analysis of 2 randomized controlled trials to determine the effect of pharmacist intervention on adverse drug events and medication errors. We studied 800 outpatient cases of hypertension stratified into complicated (n = 535) and uncomplicated (n = 265). Patients in the complicated stratum had heart failure or other cardiovascular complication. Computer programs examined 1-year electronic record data to identify events classified as adverse drug events and preventable or potential adverse drug events. Medication errors included preventable and potential adverse drug events. Of the 800 participants (mean [SD] age, 59 [10] years), 484 (90.5%) and 258 (97.4%) participants remained in the complicated and uncomplicated strata, respectively, at 12 months. Compared with the control group, the risk of any event was 34% lower in the intervention group (risk ratio, 0.66; 95% confidence interval [CI], 0.50-0.88), including a lower risk of adverse drug events (risk ratio, 0.65; 95% CI, 0.47-0.90), preventable adverse drug events (risk ratio, 0.52; 95% CI, 0.25-1.09), potential adverse drug events (risk ratio, 0.70; 95% CI, 0.40-1.22), and medication errors (risk ratio, 0.63; 95% CI, 0.40-0.98). This post hoc analysis suggests that pharmacist intervention to improve medication use in outpatients with cardiovascular disease decreases the risk of adverse drug events and medication errors. Further studies are needed to confirm this finding.

Multidisciplinary Allocation of Pain Treatment: Long-Term Outcome and Correlates of Cognitive-Behavioral Processes

Objective: To investigate the long-term effects of multidisciplinary allocation of pain treatment on pain intensity, functional disability, depression, and medication use in outpatients with chronic pain, and to identify cognitive-behavioral predictors [worrying, avoidance behavior, fear of pain, helplessness, and acceptance] of the primary outcome measures.Methods: Eighty-six outpatients with chronic pain who were treated at a multidisciplinary pain center completed various questionnaires and a pain diary one week before treatment started, and 3 and 12 months later.Results: Functional disability and depression improved significantly 12 months after the start of treatment in comparison with before treatment. The decrease in scores for the cognitive-behavioral variables worrying, fear of pain, helplessness, and avoidance behavior at three months was associated with the decrease in functional disability and depression at 12 months.Conclusion: Patients with chronic pain may benefit in the long term from mult...