Physician Prescribing Patterns Research Articles

Japanese physicians' perceptions of conflicts of interest with pharmaceutical companies: Estimating two different questioning approaches.

Despite being one of the world's largest pharmaceutical markets, interactions between Japanese physicians and pharmaceutical companies often remain opaque. Importantly, potential conflicts of interest associated with these interactions can compromise patient care and increase costs. We conducted an online survey of Japanese physicians to elucidate perspectives on pharmaceutical company promotional activities and how these influence physician prescribing patterns. Anticipating that physicians might downplay their reliance on, or the value of, pharmaceutical company-provided information, the survey incorporated a direct questioning method and an unmatched count technique (UCT) to identify hidden perceptions on factors likely to influence prescribing. Overall, 1080 eligible physicians participated. Of these, 105 (9.7%) self-identified as hospital directors or managers. Surprisingly, nearly twice as many participants responding to direct questioning (18.9%) versus those responding to the UCT (10.1%) asserted that information provided by pharmaceutical companies was important when prescribing medicine. Hospital directors or managers (adjusted odds ratio [adjOR] 2.56, 95% confidence interval [95% CI]: 1.00-6.54, reference=physician without title) and frequent interactions with pharmaceutical sales representatives (adjOR 5.96, 95% CI: 1.88-18.9, reference=rare interaction) significantly valued the information from sales representatives and sponsored lectures when considering prescribing decisions. Additionally, 77.1% of respondents believed that sales representatives provide fair, neutral, or relatively honest and unbiased information about their products. Few Japanese physicians acknowledged the influence of industry-provided information on prescribing patterns. Our study uniquely applies two distinct question formats, providing a novel approach to understanding the depth of physician-industry relationships and the effectiveness of various survey methodologies.

BEHIND THE PROTON PUMP INHIBITOR PRESCRIPTION: AN INTERNATIONAL SURVEY ON PHYSICIAN PRACTICES AND KNOWLEDGE.

Proton pump inhibitors (PPIs) are widely prescribed worldwide, often resulting in their overuse. Consequently, it is essential to identify the likely causes of this overuse to facilitate their appropriate prescription. This study aims to assess physician prescribing patterns, their knowledge of PPIs, and factors affecting their knowledge. An online survey was conducted among Latin American and Spanish physicians, collecting the following data: professional information, patterns of PPI usage, familiarity with published evidence, and the management approach in three hypothetical case-scenarios. Participant knowledge was categorized as sufficient or insufficient based on the results of the case scenarios. Subsequently, subgroup analysis was performed based on physician training level, years in practice, specialty, and time since the last PPI literature review. A total of 371 physicians participated in the survey. Thirty-eight percent frequently prescribe PPIs, primarily for prophylactic purposes (57.9%). Eighty percent were unfamiliar with PPI deprescribing strategies, and 54.4% rarely reviewed the ongoing indication of patients taking a PPI. Sixty-four percent demonstrated sufficient knowledge in the case-scenarios. A significant association was observed between specialty type (medical vs surgical: 69.4% vs 46.8%, P<0.001), the timing of the PPI indication literature review (<5 years vs >5 years: 71.4% vs 58.7%, P=0.010), and sufficient knowledge. While most participants prescribed PPIs regularly and for prophylaxis purposes, the majority were unfamiliar with deprescribing strategies and rarely reviewed ongoing indications. Sufficient knowledge is correlated with recent literature reviews and medical specialty affiliation. • The study aims to evaluate physician prescribing patterns, assess their knowledge of proton pump inhibitors, and identify factors influencing their knowledge. • An online survey of Latin American and Spanish physicians assessed proton pump inhibitor usage patterns and case-scenario responses, categorizing knowledge, and conducting subgroup analysis based on training, experience, specialty, and literature review timing. • Thirty-eight percent of surveyed physicians commonly prescribed proton pump inhibitors, and among them, 80% were unfamiliar with deprescribing strategies, with 54.4% rarely reviewing ongoing indications. • Sufficient knowledge was correlated with recent literature reviews and medical specialty affiliations.

Costs and Outcomes of Total Joint Arthroplasty in Medicare Beneficiaries Are Not Meaningfully Associated with Industry Payments.

Prior studies have demonstrated that industry payments affect physician prescribing patterns, but their effect on orthopaedic surgical costs is unknown. This study examines the relationship between industry payments and the total costs of primary total joint arthroplasty, as well as operating room cost, length of stay, 30-day mortality, and 30-day readmission. Open Payments data were matched across a 20% sample of Medicare-insured patients undergoing primary elective total hip arthroplasty (THA) (n = 130,872) performed by 7,539 surgeons or primary elective total knee arthroplasty (TKA) (n = 230,856) performed by 8,977 surgeons from 2013 to 2015. Patient, hospital, and surgeon-specific factors were gathered. Total and operating room costs, length of stay, mortality, and readmissions were recorded. Multivariable linear and logistic regression models were used to identify the risk-adjusted relationships between industry payments and the primary and secondary outcomes. In this study, 96.7% of THA surgeons and 97.4% of TKA surgeons received industry payments. After multivariable risk adjustment, for each $1,000 increase in industry payments, the total costs of THA increased by $0.50 (0.003% of total costs) and the operating room costs of THA increased by $0.20 (0.003% of total costs). Industry payments were not associated with TKA cost. Industry payments were not associated with 30-day mortality after either THA or TKA. Higher industry payments were independently associated with a marginal decrease in the length of stay for patients undergoing THA (0.0045 days per $1,000) or TKA (0.0035 days per $1,000) and a <0.1% increase in the odds of 30-day readmission after THA for every $1,000 in industry payments. The median total THA costs were $300 higher (p < 0.001), whereas the median TKA costs were $150 lower (p < 0.001), for surgeons receiving the highest 5% of industry payments. These surgical procedures were more often performed in large urban areas, in hospitals with a higher number of beds, with a higher wage index, and by more experienced surgeons and were associated with a 0.4 to 1-day shorter length of stay (p < 0.001). Although most arthroplasty surgeons received industry payments, a minority of surgeons received the majority of payments. Overall, arthroplasty costs and outcomes were not meaningfully impacted by industry relationships. Prognostic Level III . See Instructions for Authors for a complete description of levels of evidence.

Prevalence and prescribing patterns of oral corticosteroids in the United States, Taiwan, and Denmark, 2009-2018.

Oral corticosteroids (OCS) are commonly prescribed for acute, self-limited conditions, despite studies demonstrating toxicity. Studies evaluating longitudinal OCS prescribing in the general population are scarce and do not compare use across countries. This study investigated and compared OCS prescription patterns from 2009 to 2018 in the general populations of the United States, Taiwan, and Denmark. This international population-based longitudinal cohort study used nationwide claims databases (United States: Optum Clinformatics Data Mart; de-identified; Taiwan: National Health Insurance Research Database; and Denmark: National Prescription and Patient Registries/Danish National Patient Registry) to evaluate OCS prescribing. We classified annual OCS duration as short-term (1-29 days), medium-term (30-89 days), or long-term (≥90 days). Longitudinal change in annual prevalence of OCS use and physician prescribing patterns were reported. Among 54,630,437 participants, average annual percentage of overall OCS use was 6.8% in the United States, 17.5% in Taiwan, and 2.2% in Denmark during 2009-2018. Prevalence of OCS prescribing increased at an average annual rate of 0.1%-0.17%, mainly driven by short-term prescribing to healthy adults. One-quarter to one-fifth of OCS prescribing was associated with a diagnosis of respiratory infection. Family practice and internal medicine physicians were among the highest OCS prescribers across countries and durations. Age- and sex-stratified trends mirrored unstratified trends. This study provides real-world evidence of an ongoing steady increase in OCS use in the general populations of the United States, Taiwan, and Denmark. This increase is largely driven by short-term OCS prescribing to healthy adults, a practice previously viewed as safe but recently shown to incur substantial population-level risk.

E051 A systematic review of audit and feedback tools to reduce opioid prescribing for chronic non-cancer pain

Abstract Background/Aims Opioid prescribing has increased considerably over the 15 years for chronic non-cancer pain in the UK, including for musculoskeletal conditions. Whilst there are national and international guidelines to reduce inappropriate opioid prescribing, these are not always adhered to in practice. Audit and feedback is a common intervention for supporting clinical behaviour change. Little is known if such tools have been used to support safer opioid prescribing to date. This systematic review aimed to describe audit and feedback tools that were designed, implemented and led to changes in opioid prescribing practices. Methods A systematic review of the literature was performed as per the Preferred Reporting Items for Systematic Reviews and Meta-Analyses framework (PRISMA). Both Embase and MEDLINE were searched to identify studies that included audit and feedback tools in patients prescribed opioids with chronic non-cancer pain until the 31st of May 2021. Results Of the 539 studies imported, following removal of duplicates, 497 studies were screened. Following title and abstract review 6 full-text studies were assessed for eligibility. A total of three studies were deemed to meet inclusion criteria. Approaches found included: The Controlled Medication Advisory Board (CMAB), Systems Consultation and the Opioid Safety Initiative (OSI). CMAB involved the use of a dashboard to provide feedback to clinicians on referred patients. As a result the opioid prescribing rate per 100 patient visits decreased by 31% and the rate of co-prescription of benzodiazepines and opioids decreased by 56%. Systems Consultation involved the use of audit and feedback, academic detailing and external facilitation to reduce opioid prescribing. Systems consultation resulted in a statistically significant reduction in the morphine equivalent daily doses. The OSI used automatic electronic medical records auditing to enable clinic leaders to identify physician prescribing patterns via a dashboard. OSI enabled a 9.9% reduction in opioid prescriptions from 571,476 to 514,883. Conclusion Computerised audit and feedback tools may be effective interventions to support opioid stewardship initiative and promote safer opioid prescribing. Such approaches being used internationally could pave the way for similar initiatives in the UK and future research evaluating their impact on patient safety. Disclosure J. Feldman: None. M. Jani: Grants/research support; National Institute for Health and Care Research Advanced Fellowship (NIHR301413).

Assessment and Management of Hospital Acquired Infections in a Tertiary Care Hospital

Abstract: Aim: To assess hospital acquired infections and its management in a tertiary care hospital. Materials and Methods: A cross-sectional study of six months was carried out. Utilizing SPSS Version 25 and Microsoft Office Excel, statistical analysis was carried out, after the collected data were imported into Excel. Results: In our investigation, the prevalence of hospital acquired infections was discovered to be 6.1%. Male patients made up 70% of study’s total participants while female made up 30%. The highest distribution of Hospital Acquired Infections (HAI) was found to be Bloodstream Infection (BSI) (41.80%), followed by Hospital-Acquired Pneumonia (HAP) (17.20%), Respiratory tract infections (RTI) (13.90%) and other HAI. (Hospital Aquired Infections). Most common causative organism was found to be as Klebsiella pneumoniae (15.46%). According to lab investigations, Leukocytosis (61.47%), Neutrophilia (59.83%), Lymphopenia (78.68%), Hyperglycaemia (53.3%) and elevated level of CRP (81.13%) was found in majority patients. Most of the patients were treated with Meropenem (17.55%), Linezolid (15.98%) and others. Conclusion: Hospital acquired infections are a significant risk to medical facilities and one of the most often avoidable negative patient outcomes. They make a major contribution to hospital expenses and mortality rates. The basis of effective infection control programmes in hospitals can be the monitoring of antibiotic resistance in conjunction with tracking physician prescribing patterns. Keywords: Hospital Acquired Infections (HAI), Nosocomial infections, Causative organism, Prevalence.

Abstract P4-07-06: Implementation of A Bone Modifying Agent Pathway at UChicago Medicine for Metastatic Breast Cancer Patients

Abstract Background: In 2019, a quality improvement (QI) research project was conducted at UChicago Medicine (UCM) to evaluate bone modifying agent (BMA) use for skeletal-related event (SRE) prevention in patients with metastatic breast cancer and metastatic castration-resistant prostate cancer. Denosumab was the preferred BMA agent at UCM in this setting. Compared to zoledronic acid (ZA), denosumab was associated with higher drug cost and lower adherence rate mainly due to the difficulty of maintaining the 4-weekly frequency. Studies have shown that ZA can be de-escalated from 4-weekly to 12-weekly for SRE prevention. There is still no convincing evidence to show that this de-escalated schedule can be applied to denosumab. One study evaluated the noninferiority of 12-weekly compared with 4-weekly denosumab suggested that the health-related quality of life was non-inferior (Clemons et al., 2021). However, the study was not powered to evaluate the statistical difference in SRE rates. Based on the results of the 2019 QI project, a BMA pathway was generated at UCM in September 2020 with the purpose of guiding physician prescribing patterns, improving adherence rate, and reducing drug costs. This pathway recommended using ZA as the preferred agent for SRE prevention instead of denosumab. Methods: This was a retrospective study that included 198 patients who had metastatic breast cancer and received at least one dose of ZA or denosumab from UCM outpatient oncology clinic for SRE prevention. All included patients must have bone metastases. 107 patients from the pre-implementation study period (July 1st, 2018 to June 30th, 2019) and 91 patients from the post-implementation study period (November 10th, 2020 to November 10th, 2021) were included. Patients were divided into four groups based on study time (pre- or post-implementation period) and BMA agent (ZA and denosumab). The primary outcome was BMA therapy adherence rate, which was defined by those who received greater than or equal to 80% of appropriately scheduled doses. Secondary outcomes included the percentage of patients on ZA or denosumab, SREs, BMA-associated adverse effects, and BMA cost. Descriptive statistics were used SREs and BMA-associated adverse effects. Results: The percentage of patients on ZA significantly increased from 12% to 64% after BMA pathway implementation (P&amp;lt; 0.0001). Denosumab use decreased from 88% to 36% (P&amp;lt; 0.0001). The overall BMA adherence rate including both ZA and denosumab patients during the post-implementation period was 68%, which was not significantly different compared to the overall adherence rate of 74% during the pre-implementation period (P=0.5461). The adherence rates in denosumab groups (63% in pre and 30% in post) were lower than in ZA groups (100% in pre and 90% in post). The most common reason for the lower adherence rates in denosumab groups was scheduling convenience. During the study period, there were 2, 0, 3, and 3 patients who had SREs in the above four groups respectively. The predominant adverse events among all groups were hypocalcemia and hypophosphatemia. The cost analysis showed using ZA as the primary BMA agent saved 1.1 million dollars of drug costs during the post-implementation study period at UCM. Conclusion: Implementing a BMA pathway encouraged the providers to choose ZA as the preferred agent for SRE prevention in metastatic breast cancer patients with bone metastasis, which dramatically reduced drug costs. The overall BMA adherence rate was not significantly improved with the implementation. The difficulty of maintaining a 4-weekly denosumab frequency continued to exist. Citation Format: Kun Lin, Jordan Baur, Sandeep Parsad, Heng Yang. Implementation of A Bone Modifying Agent Pathway at UChicago Medicine for Metastatic Breast Cancer Patients [abstract]. In: Proceedings of the 2022 San Antonio Breast Cancer Symposium; 2022 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2023;83(5 Suppl):Abstract nr P4-07-06.

Do published trial results influence physician prescribing patterns? Intravitreal antivascular endothelial growth factor usage by the United States Ophthalmologists before and after Protocol T study.

Clinical trial publications may influence physician prescribing patterns. The Diabetic Retinopathy Clinical Research Network (DRCR.net) Protocol T study, published in 2015, examined outcomes of intravitreal antivascular endothelial growth factor (VEGF) medications for treatment of diabetic macular oedema (DME). This study investigates if the Protocol T 1-year results were associated with changes in prescribing patterns. Anti-VEGF agents have revolutionized treatment of DME by blocking angiogenesis signalled by VEGF. Three commonly used anti-VEGF agents are on-label aflibercept (Eylea, Regeneron) and ranibizumab (Lucentis, Genentech) and off-label bevacizumab (Avastin, Genentech). From 2013 to 2018, there was a significant positive trend in the average number of aflibercept injections for any indication ( P < 0.002). There was no significant trend in the average number of bevacizumab ( P = 0.09) and ranibizumab ( P = 0.43) for any indication. The mean proportion of aflibercept injections per provider per year was 0.181, 0.217, 0.311, 0.403, 0.419 and 0.427; each year-by-year comparison was significant (all P < 0.001), and the largest increase was in 2015, the year of publication of Protocol T 1-year results. These results imply and reinforce that clinical trial publications may have significant effects on ophthalmologist prescribing patterns.

Sustained usage of an app-based clinical-decision making aid for the management of atherosclerotic cardiovascular disease

Abstract Background Complexity of therapies for atherosclerotic cardiovascular disease (ASCVD) risk reduction represents a challenge for clinicians and may lead to poor uptake of these therapies. Purpose The goal of this project was to design an easy-to-use, point-of-care tool to risk stratify ASCVD patients and provide individualized guidance for clinicians to incorporate these agents. Methods Based on the REACH registry trial and predictive modeling (including 49,689 patients with ASCVD in 44 countries), we designed and implemented an app for secondary risk assessment. Using demographic and comorbidity profiles, this tool was used to calculate an individual's 20-month risk of cardiovascular events and mortality. It also provided graphical comparison to an age-matched control with optimized cardiovascular risk profile to illustrate the modifiable residual risk. The app then utilized the patient's risk profile to provide specific guidance for possible therapeutic interventions SGLT2-inhibitors, GLP1-agonists, PCSK9-inhibitors, Vascular-dose Rivaroxaban, and Icosapent Ethyl. Additionally, it identified individuals who qualified for cardiac rehabilitation or may benefit from smoking cessation interventions, including counselling or pharmacological therapies. We launched a pilot test of the “Residual Cardiovascular Risk: Assessment and Management Guide” app at a regional cardiac center. 240 referring physicians (including family doctors, emergency physicians, internists, and cardiologists) were invited by email or fax to utilize the app. Feedback was solicited from all users three months into the test period. Following this, no further marketing of the app was performed for all users. Usage data was recorded using Google Analytics over a 12-month period and analyzed in 4-month increments. Results From January to December 2021, our app was used to risk stratify 1576 patients. A total of 47 individual users utilized the app over this period. From January to April, the app was used on average 160 times monthly. From May to August, it was used 115 times monthly. From September to December, it was used 118 times monthly. Twenty-four physicians provided feedback; 100% affirmed the functionality, ease of use, and utility of the tool. The app was described as “useful for discussions with patients”, “helpful to optimize patients” and “similar to a mini-cardiology consult”. User suggestions resulted in further improvements to the app, including integration of reports into Electronic Medical Records. Conclusions The early success of this app demonstrates a need for simple, accessible, and individualized guidance for management of ASCVD patients to improve uptake of guideline-based medical therapies. This tool demonstrates sustained usage among clinicians, as well as subjective utility in aiding therapeutic decision making. Future clinical research will focus on the ability of this tool to impact physician prescribing patterns and clinical outcomes. Funding Acknowledgement Type of funding sources: None.

Sustained usage of an app-based clinical-decision making aid for the management of atherosclerotic cardiovascular disease

Abstract Background Complexity of therapies for atherosclerotic cardiovascular disease (ASCVD) risk reduction represents a challenge for clinicians and may lead to poor uptake of these therapies. Purpose The goal of this project was to design an easy-to-use, point-of-care tool to risk stratify ASCVD patients and provide individualized guidance for clinicians to incorporate these agents. Methods Based on the REACH registry trial and predictive modeling (including 49,689 patients with ASCVD in 44 countries), we designed and implemented an app for secondary risk assessment. Using demographic and comorbidity profiles, this tool was used to calculate an individual's 20-month risk of cardiovascular events and mortality. It also provided graphical comparison to an age-matched control with optimized cardiovascular risk profile to illustrate the modifiable residual risk. The app then utilized the patient's risk profile to provide specific guidance for possible therapeutic interventions SGLT2-inhibitors, GLP1-agonists, PCSK9-inhibitors, Vascular-dose Rivaroxaban, and Icosapent Ethyl. Additionally, it identified individuals who qualified for cardiac rehabilitation or may benefit from smoking cessation interventions, including counselling or pharmacological therapies. We launched a pilot test of the “Residual Cardiovascular Risk: Assessment and Management Guide” app at a regional cardiac center. 240 referring physicians (including family doctors, emergency physicians, internists, and cardiologists) were invited by email or fax to utilize the app. Feedback was solicited from all users three months into the test period. Following this, no further marketing of the app was performed for all users. Usage data was recorded using Google Analytics over a 12-month period and analyzed in 4-month increments. Results From January to December 2021, our app was used to risk stratify 1576 patients. A total of 47 individual users utilized the app over this period. From January to April, the app was used on average 160 times monthly. From May to August, it was used 115 times monthly. From September to December, it was used 118 times monthly. Twenty-four physicians provided feedback; 100% affirmed the functionality, ease of use, and utility of the tool. The app was described as “useful for discussions with patients”, “helpful to optimize patients” and “similar to a mini-cardiology consult”. User suggestions resulted in further improvements to the app, including integration of reports into Electronic Medical Records. Conclusions The early success of this app demonstrates a need for simple, accessible, and individualized guidance for management of ASCVD patients to improve uptake of guideline-based medical therapies. This tool demonstrates sustained usage among clinicians, as well as subjective utility in aiding therapeutic decision making. Future clinical research will focus on the ability of this tool to impact physician prescribing patterns and clinical outcomes. Funding Acknowledgement Type of funding sources: None.

Actual situation and prescribing patterns of opioids by pain physicians in South Korea.

BackgroundUse of opioids for chronic intractable pain is increasing globally, and their proper use can improve patients’ quality of life. In contrast, opioid use disorders, such as abuse or addiction, caused by prescribing opioids, are a worldwide issue. This study aimed to understand current opioid prescribing patterns and pain physicians’ experiences with opioid use in South Korea.MethodsPain physicians in 42 university hospitals in South Korea were asked to complete anonymous questionnaires regarding opioid prescriptions.ResultsA total of 69 surveys were completed. Most pain physicians started prescribing opioids at a pain score of 7/10 and aimed to reduce pain by 50%. Most physicians (73.1%) actively explained the prescribed medications and possible side effects, and 61.2% of physicians preferred the prescription interval of 4 weeks. Immediate-release opioids were the most popular treatment for breakthrough pain (92.6%). The most common side effect encountered by physicians was constipation (43.3%), followed by nausea/vomiting (34.3%). Of the physicians, 56.5% replied that addiction and misuse prevalences were less than 5%. However, the most concerning side effect was addiction (33.0%).ConclusionsThe survey results showed that the prescribing patterns of pain physicians generally followed Korean guidelines. Physicians were most interested in the safety and effectiveness of opioid prescriptions. They were most concerned about respiratory depression and abuse or addiction. A significant number of physicians agreed that the NHIS regulations needed improvement for patient convenience and safe and effective treatment, though there were pros and cons of the NHIS restrictions on prescription conditions.

Aiding the prescriber: developing a machine learning approach to personalized risk modeling for chronic opioid therapy amongst US Army soldiers.

The opioid epidemic is a major policy concern. The widespread availability of opioids, which is fueled by physician prescribing patterns, medication diversion, and the interaction with potential illicit opioid use, has been implicated as proximal cause for subsequent opioid dependence and mortality. Risk indicators related to chronic opioid therapy (COT) at the point of care may influence physicians' prescribing decisions, potentially reducing rates of dependency and abuse. In this paper, we investigate the performance of machine learning algorithms for predicting the risk of COT. Using data on over 12 million observations of active duty US Army soldiers, we apply machine learning models to predict the risk of COT in the initial months of prescription. We use the area under the curve (AUC) as an overall measure of model performance, and we focus on the positive predictive value (PPV), which reflects the models' ability to accurately target military members for intervention. Of the many models tested, AUC ranges between 0.83 and 0.87. When we focus on the top 1% of members at highest risk, we observe a PPV value of 8.4% and 20.3% for months 1 and 3, respectively. We further investigate the performance of sparse models that can be implemented in sparse data environments. We find that when the goal is to identify patients at the highest risk of chronic use, these sparse linear models achieve a performance similar to models trained on hundreds of variables. Our predictive models exhibit high accuracy and can alert prescribers to the risk of COT for the highest risk patients. Optimized sparse models identify a parsimonious set of factors to predict COT: initial supply of opioids, the supply of opioids in the month being studied, and the number of prescriptions for psychotropic medications. Future research should investigate the possible effects of these tools on prescriber behavior (e.g., the benefit of clinician nudging at the point of care in outpatient settings).

Influence of Primary Care Provider Type on Chronic Pain Management Among Veterans

Chronic pain disproportionately impacts veterans and is often treated in primary care, where physician shortages in the Veterans Health Administration (VHA) healthcare system are well documented. Nurse practitioners (NPs) may represent a solution to the care shortage; however, concerns of NP opioid overprescribing have led to NP practice and prescribing restrictions in individual VHA facilities and at the state level. Little is known regarding the prescribing patterns of NPs and physician assistants (PAs) for veterans with chronic pain in the VHA. The purpose of this study was to compare opioid and non-opioid prescribing patterns of physicians, NPs, and PAs for chronic pain patients at VHA centers. We used data from the U.S. Department of Veterans Affairs Survey of Healthcare Experience of Patients and Corporate Data Warehouse from October 2015 to September 2016. Patient medical records for the year were analyzed by provider type (physician, NP, or PA) for differences in providers' rates of prescribing opioid and non-opioid medications, as well as characteristics of the opioid prescriptions (e.g., high daily morphine milligram equivalent [90 MME/day] dose, long-term opioid therapy [90 days]). Medical records of a total of 39,936 patients were included. In FY 2016, 55% of patients received one opioid prescription, whereas 83.8% received one non-opioid prescription. Compared to patients of NPs and PAs, patients of physicians had higher odds of receiving opioid (vs. NPs: OR = 1.13, p < 0.01; vs. PAs: OR = 1.16, p < 0.01) and non-opioid prescriptions (vs. NPs: OR=1.08, p = 0.02; vs. PAs: OR=1.20, p < 0.01) after adjusting for patient characteristics. There were no differences in high MME/day dose (p = 0.59) or long-term opioid therapy (p = 0.99). In a national sample of veterans with chronic pain, NPs and PAs did not have higher odds of opioid prescribing. Concerns of NP or PA opioid overprescribing may be addressed by considering evidence that patients of these providers are not at higher odds of receiving an opioid prescription.

Evaluation of Carbapenem Use Before and After Implementation of an Antimicrobial Stewardship-Led Carbapenem-Sparing Strategy in a Lebanese Tertiary Hospital: A Retrospective Study.

PurposeThe use of carbapenem before and after implementation of an antimicrobial stewardship-led carbapenem-sparing strategy at a tertiary care center in Lebanon was evaluated.MethodsA retrospective, observational chart review was performed on all hospitalized pediatric and adult patients who received carbapenem therapy during January 2019 and January 2020. Patients who started their regimen before January or received carbapenems for less than 24 hours were excluded. Primary outcomes included the appropriateness of physician prescribing patterns and pharmacists’ interventions, as well as appropriateness and response rates of the latter. Secondary outcomes included the carbapenem defined daily dose (DDD) and days of therapy (DOT). Descriptive statistics were used in the analysis and a p-value < 0.05 was considered to be statistically significant.ResultsA total of 157 and 150 patients charts were reviewed in January 2019 and January 2020, respectively. There was no difference in baseline characteristics except for inpatient services and rates of isolated multidrug-resistant organisms. When comparing the two timelines, the appropriateness of physicians’ prescribing patterns increased in terms of empirical therapy, targeted therapy, and duration of therapy but the results were not statistically significant. Pharmacists’ interventions significantly increased with regards to the duration of therapy (p= <0.001), dose adjustment (p<0.001), de-escalation to a narrower spectrum antibiotic (p=0.007), and use of extended infusion (p=0.042). The DDD and DOT were higher for ertapenem and lower for anti-pseudomonal carbapenems in January 2020.ConclusionThe carbapenem-sparing strategy adopted by the antimicrobial stewardship program contributed to an increase in the number of interventions made by pharmacists on carbapenem therapy, including their appropriateness, and response rate. Despite an improvement in the physician-prescribing patterns, more awareness and education may be needed to achieve a better impact.

The Effect of an Electronic Prescribing Policy for Opioids on Physician Prescribing Patterns Following Common Upper Extremity Procedures

PurposeWe evaluated physician prescribing patterns before and after the implementation of a state-mandated opioid electronic prescribing (ePrescribing) program after 4 common outpatient hand surgeries. Specifically, we aimed to answer the following: (1) is there a change in the number of opioids prescribed after the institution of ePrescribing for carpal tunnel release (CTR), ganglion excision, distal radius fracture (DRF) open reduction internal fixation (ORIF), and carpometacarpal (CMC) arthroplasty and (2) what factors are associated with an increased number of tablets or total morphine milligram equivalents (MMEs) prescribed.MethodsWe retrospectively reviewed patients who underwent CTR, ganglion excision, DRF ORIF, or CMC arthroplasty and analyzed the number of tablets and MMEs prescribed before and after the policy implementation, as well as which factors were associated with an increased total number of opioid tablets and MMEs prescribed.ResultsA total of 428 patients were included. After policy implementation, there was a significant decrease in MMEs prescribed for ganglion excision (68 [SD, 45] vs 50 [SD, 60], P = .03) and CMC arthroplasty (283 [SD, 147] vs 217 [SD, 92], P < .01). There was also a significant decrease in the total number of tablets prescribed for ganglion excision (11 [SD, 5.7] vs 6.8 [SD, 8.0], P < .01), CMC arthroplasty (36 [SD, 13] vs 29 [SD, 12], P < .01), and DRF ORIF (31 [SD, 8.6] vs 28 [SD, 8.5], P = .04). The number of patients receiving any opioid prescription also significantly decreased following CTR (30% vs 51%, P = .03) and ganglion excision (11% vs 53%, P < .01).ConclusionsThe initiation of state-mandated ePrescribing was associated with a decreased number of opioids—both MMEs and tablets—prescribed after surgery by hand surgeons for a variety of common procedures. Furthermore, a greater percentage of patients received no opioid prescriptions after ePrescribing. These findings support the value of ePrescribing as a potential tool to further decrease excess opioid prescriptions.Type of study/level of evidenceTherapeutic III.

Influence of provider type on chronic pain prescribing patterns A systematic review.

Chronic pain affects 100 million Americans and is most often treated in primary care, where the health care provider shortage remains a challenge. Nurse practitioners (NPs) represent a growing solution, yet their patterns of chronic pain management are understudied. Additionally, prescriptive authority limitations in many states limit NPs from prescribing opioids and often exist due to concerns of NP-driven opioid overprescribing. Little evidence on NP pain management prescribing patterns exists to address these issues. Systematic review, according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, to examine opioid and nonopioid prescribing patterns of physicians, NPs, and physician assistants (PAs) in primary care. Eligible studies scored ≥60% on the Joanna Briggs Institute Critical Appraisal checklist. Searches within PubMed, Embase, CINAHL, and Web of Science. Three themes were elucidated: 1) opioid prescribing in primary care, 2) similarities and differences in opioid prescribing by provider type, and 3) nonopioid pain management strategies. All provider groups had similar opioid prescribing patterns, although NPs and PAs may be slightly less likely to prescribe opioids than physicians. Although some studies suggested that NPs/PAs had higher opioid prescribing rates compared with physicians, methodological flaws may undermine these conclusions. Evidence is also lacking on nonopioid prescribing patterns across disciplines. Nurse practitioner/PA prescriptive authority limitations may not be as effective of a solution for addressing opioid overprescribing as transdisciplinary interventions targeting the highest subset of opioid prescribers. Future research should examine prescribing patterns of nonopioid, including nonpharmacologic, therapies.

250 Clinical Pharmacist Screening and Intervention on Penicillin Use in the Emergency Department Among Patients With a Stated History of Penicillin Allergy

The reported prevalence of penicillin allergy in the US adult population ranges between 10-20%. However, when evaluated, fewer than 1% of the population has a true allergy. The objective of this study is to determine the impact on physician prescribing patterns, after patients presenting to the emergency department with a stated history of penicillin allergy undergo allergy risk stratification following a structured interview by a clinical pharmacist. This is a prospective, pilot study of all patients over the age of 18 with a stated allergy to penicillin presenting to the emergency department during the hours a clinical pharmacist is on-duty (N = 44). The study site is a suburban, academic, tertiary-care center with an annual volume of 80, 000 visits. Patients identified as penicillin allergic were interviewed by a clinical pharmacist using a nine-question, structured interview to determine allergy risk stratification (low, medium, high). The questionnaire results and risk stratification were entered into the electronic medical record for physician reference. Physicians then made an independent decision to use a beta-lactam versus a non-beta-lactam alternative if the patient required antibiotic treatment during their course of care. The overall sample demographic characteristics consisted of 68.2% females and 31.8% males, 15.9% African American, 15.9% Other/Multiracial, 68.2% White, age range 28-90 (M = 56.4, SD = 13.4). With regard to their allergy, 77.3% reported it occurred greater than 10 years ago, with 52.3% reporting rash only, and 31.8% having additional medication allergies. Risk stratification of the entire group yielded 56.8% low risk, 25.0% medium risk, and 18.2% high risk. A total of 52.3% (n = 23) of the interviewed patients required antibiotic treatment for infections (26.1% genitourinary, 26.1% sepsis, 21.7% respiratory, 13.0% skin, 13.0% gastrointestinal). Risk stratification of the treatment group yielded 60.9% low risk, 17.4% medium risk, and 21.7% high risk. Physicians prescribed a beta-lactam to 87.0% of the patients in the treatment group (n = 20) without any adverse outcomes (low-risk: n = 14, medium-risk: n = 2, high-risk: n = 4). Penicillin allergy labeling may incorrectly follow a patient creating downstream negative impacts including exposure to broad spectrum antibiotics, increased rates of antibiotic resistance, and prolonged hospital stays. The results of this study suggest using a pharmacy-driven, structured interview format to risk stratify patients, increases the likelihood that they will receive a beta-lactam during their treatment. Future studies with larger samples are needed in order to capture the potential outcomes and better understand the number of individuals who are truly allergic to penicillin and whether the structured interview is a more accurate screening tool than self-report.

Physician Prescribing and Referral Patterns in Children with Cerebral Visual Impairment.

Cerebral visual impairment (CVI) is the leading cause of visual impairment in the developed world. Providing children with CVI with the appropriate treatment ensures the best possible visual outcome and potentially improves quality of life. The purpose of this study was to determine physician prescribing and visual rehabilitation referral patterns in children with CVI. A retrospective chart review was completed on children with CVI examined at Cincinnati Children's Hospital Medical Center from January 1, 2008, to March 1, 2018. Significant refractive error warranting correction was determined using the American Academy of Ophthalmology Preferred Guidelines and the American Association for Pediatric Ophthalmology and Strabismus Vision Screening Committee Guidelines. The CVI Range was used as a surrogate to categorize CVI severity. A total of 194 children were included. Sixty-eight (35%) had refractive error warranting correction and were prescribed glasses (group RC), 99 (51%) did not have refractive error warranting correction and were not prescribed glasses (group NRNC), 20 (10%) had refractive error warranting correction but were not prescribed glasses (group RNC), and 7 (4%) did not have refractive error warranting correction but were prescribed glasses (group NRC). There was greater than one-line Snellen equivalent difference between group RC (20/156) and group RNC (20/221). There was greater than six-line Snellen equivalent difference between group NRNC (20/149) and group NRC (20/35). Mean CVI Range score 2 values for each group were 5.9, 4.6, 4.8, and 7.1. Children with less severe CVI were less likely to have significant refractive error but given glasses. Despite significant refractive error, children with more severe CVI were not prescribed glasses. Children with very low visual function were not prescribed glasses as frequently, possibly limiting their visual rehabilitation. Providers should ensure that all children with CVI are correctly prescribed glasses to provide the best possible visual outcome.

The effect of physician prescribing patterns based on ESC guidelines on morbidity improvement among heart failure patients

Data from Basic Health Research shows the prevalence of heart failure in Indonesia is between 0.1% to 0.3% of the entire Indonesian population. This number is predicted to increase from year to year. Heart failure is a complex syndrome that can cause abnormalities in the structure and function of the heart. Based on the ejection fraction values, there are three types of heart failure, namely HFrEF (EF: &lt; 40%), HFmrEF (EF: 40-49%), and HFpEF (EF: ≥ 50%). Considering that the type of heart failure requiring treatment according to ESC guidelines is only HFrEF, however, this study would also evaluate the effect of physician prescribing patterns on the morbidity of HFmrEF. The recommendations from ESC guidelines to the treatment of HFrEF that can reduce morbidity and mortality are three medication combinations, namely ACE inhibitors/angiotensin receptor blockers, beta-blockers, and aldosterone antagonists. Therefore, this study aims to determine the effect of the suitability of physician prescribing patterns according to ESC guidelines on improving the morbidity of heart failure patients in HFrEF and HFmrEF type. Improvements in morbidity can be seen from the quality of life score and frequency of hospitalization by using questionnaires. The study was conducted in the cardiology outpatient clinic of Dr. Saiful Anwar General Hospital and Islamic Hospital of Aisyiyah in April-May 2019. Subjects who participated in the study were 57 patients. The One-way ANOVA test results showed no significant difference between physician prescribing patterns of quality of life scores on HFrEF (p = 0.944) while the Kruskal Wallis test for the same parameters on HFmrEF also showed insignificant results (p = 0.210). The Kruskal Wallis test results showed no significant difference between the patterns of physician prescribing to the frequency of hospitalization in both HFrEF and HFmrEF (p = 0.260; p = 0.428). The results showed that physician prescribing patterns in accordance with ESC guidelines resulted in the best quality of life scores on HFrEF. The lowest frequency of hospitalization was also shown in HFrEF patients who received treatment according to ESC guidelines.

Trends in prescribing patterns of proton pump inhibitors surrounding new guidelines

PurposeThe purpose of this study was to examine whether the latest National Institute for Health and Care Excellence proton pump inhibitor (PPI) guidelines changed physician prescribing patterns in clinical practice. MethodsUsing data from the United Kingdom Clinical Practice Research Datalink, we calculated monthly PPI prescribing rates in adults by dividing the number of PPI prescriptions by the number of patients in each calendar month. Using these rates, we conducted an interrupted time-series analysis to compare PPI prescription rates before (September 2010–August 2014) and after (September 2014–August 2018) guideline publication, estimating a slope and level change using segmented autoregression. ResultsIn the preguideline period, monthly PPI prescription rate increased by 46.9 (95% confidence interval (CI): 40.8 to 53.0) prescriptions per 100,000 persons. Following guideline publication, there was no immediate change in the monthly PPI prescribing rate (137.6, 95% CI: −36.7 to 311.9 prescriptions per 100,000 persons), but there was a modest attenuation of the change in monthly rate (−23.9, 95% CI: −14.0 to −33.6 prescriptions per 100,000 persons). However, the predicted rates mirror the observed rates after guideline publication, suggesting limited changes. ConclusionsDespite efforts to minimize the overprescribing of PPIs, there was little meaningful change in clinical practice following the 2014 National Institute for Health and Care Excellence recommendations.