Physician Prescribing Research Articles

Fluoride Prescribing Behaviors for Medicaid-Enrolled Children in Oregon

This study aims to examine physician and dentist fluoride prescription patterns and identify the factors associated with fluoride prescriptions for Medicaid-enrolled children. The hypothesis is that dentists will be the primary prescribers of fluoride and that caries risk factors will be associated with fluoride prescriptions. Data were analyzed for Oregon children aged 0-17 years enrolled in Medicaid for ≥300 days in both 2016 and 2017. The outcome variable was receiving a fluoride prescription in 2017. A 2-tailed chi-square test was used to assess fluoride prescribing differences between physicians and dentists. Multivariable logistic regression models were used to examine the likelihood of receiving a fluoride prescription in 2017 and to generate ORs. Model covariates included child's age, sex, race, ethnicity, Medicaid plan type, previous fluoride prescription, previous restorative dental treatment, and water fluoridation status. Of 200,169 Medicaid-enrolled children, 6.7% (n=13,337) received fluoride prescriptions. Physicians were >3 times as likely to prescribe fluoride as dentists (73.4% vs 23.0%, p<0.001). Children with a history of fluoride prescriptions (OR=14.30, p<0.001) and any restorative dental treatment (OR=1.58, p<0.001) were significantly more likely to receive a fluoride prescription, whereas children living in areas with water fluoridation were significantly less likely (OR=0.50, p=0.01). Physicians play an important role in prescribing fluoride to Medicaid-enrolled children, especially those at increased dental caries risk. Additional research is needed on strategies to ensure that all high-risk children have an opportunity to benefit from prescription fluoride.

Pharmaceutical opioid marketing and physician prescribing behavior.

Physicians' relationships with the pharmaceutical industry have recently come under public scrutiny, particularly in the context of opioid drug prescribing. This study examines the effect of doctor-industry marketing interactions on subsequent prescribing patterns of opioids using linked Medicare Part D and Open Payments data for the years 2014-2017. Results indicate that both the number and the dollar-value of marketing visits increase physicians' patented opioid claims. Furthermore, direct-to-physician marketing of safer abuse-deterrent formulations of opioids is the primary driver of positive and persistent spillovers on the prescribing of less safe generic opioids - a result that we show appears to be driven by insurance coverage policies. These findings suggest that pharmaceutical marketing efforts may have unintended public health implications.

Association of Patient Race and Ethnicity With Differences in Opioid Prescribing by Primary Care Physicians for Older Adults With New Low Back Pain

Substantial patient racial and ethnic differences in opioid prescribing have been documented, but how much of these differences were attributable to physicians prescribing opioids differently to patients of racial and ethnic minority groups is unknown, particularly during the first wave of the opioid epidemic when the dangers of opioid prescribing and use were not as well known. To examine associations of patient race and ethnicity with differences in opioid prescribing by the same primary care physician (PCP) for new low back pain episodes among older adults from 2007 to 2014. This cross-sectional study used Medicare data of PCP office visits by Medicare beneficiaries who were 66 years or older with new low back pain. Prescribing of any opioid in the first year of a new low back pain episode (days 1-365) and subsequent long-term use of an opioid (prescribed for ≥180 days in days 366-730). Among the study population of 274 771 patients (mean [SD] age, 77.1 [7.2] years; 192 105 [69.9%] women) with new low back pain, 15 285 (6%) were Asian or Pacific Islander, 16 079 (6%) were Black, 21 289 (8%) were Hispanic, and 222 118 (81%) were White, cared for by 63 494 physicians. In adjusted analysis, on average, 11.5% of the White patients (95% CI, 11.4 to 11.6) received an opioid prescription in the first year of new low back pain. The same prescribing physician was 1.5 percentage points (PP; 95% CI, -2.2 PP to -0.8 PP) less likely to prescribe an opioid if the patient was Black, 2.7 PP (95% CI, -3.5 PP to -1.8 PP) less likely if the patient was Asian or Pacific Islander, and 1.0 PP (95% CI, -1.7 PP to -0.3 PP) less likely if the patient was Hispanic. The same physician was more likely to prescribe a prescription nonsteroidal anti-inflammatory drug to a patient of a racial or ethnic minority group. White patients with new low back pain were more likely to develop subsequent long-term opioid use than patients of racial and ethnic minority groups (eg, 1.8% for White patients vs 0.5% for Hispanic patients). This cross-sectional study found that from 2007 to 2014, primary care physicians prescribed opioids for new low back pain more often to White patients than to patients of racial and ethnic minority groups. These results suggest that there may have been unequal treatment of pain by physicians when less was known about the morbidity associated with opioid use.

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.

High-risk Opioid Prescribing Associated with Postoperative New Persistent Opioid Use in Adolescents and Young Adults.

In this study, we explored which postoperative opioid prescribing practices were associated with persistent opioid use among adolescents and young adults. Approximately 5% of adolescents and young adults develop postoperative new persistent opioid use. The impact of physician prescribing practices on persistent use among young patients is unknown. We identified opioid-naïve patients aged 13 to 21 who underwent 1 of 13 procedures (2008-2016) and filled a perioperative opioid prescription using commercial insurance claims (Optum Deidentified Clinformatics Data Mart Database). Persistent use was defined as ≥ 1 opioid prescription fill 91 to 180 days after surgery. High-risk opioid prescribing included overlapping opioid prescriptions, co-prescribed benzodiazepines, high daily prescribed dosage, long-acting formulations, and multiple prescribers. Logistic regression modeled persistent use as a function of exposure to high-risk prescribing, adjusted for patient demographics, procedure, and comorbidities. High-risk opioid prescribing practices increased from 34.9% to 43.5% over the study period; the largest increase was in co-prescribed benzodiazepines (24.1%-33.4%). High-risk opioid prescribing was associated with persistent use (aOR 1.235 [1.12,1.36]). Receipt of prescriptions from multiple opioid prescribers was individually associated with persistent use (aOR 1.288 [1.16,1.44]). The majority of opioid prescriptions to patients with persistent use beyond the postoperative period were from nonsurgical prescribers (79.6%). High-risk opioid prescribing practices, particularly receiving prescriptions from multiple prescribers across specialties, were associated with a significant increase in adolescent and young adult patients' risk of persistent opioid use. Prescription drug monitoring programs may help identify young patients at risk of persistent opioid use.

Korean physician prescription patterns for home oxygen therapy in chronic obstructive pulmonary disease patients.

Background/AimsHypoxemia in chronic obstructive pulmonary disease (COPD) leads to reduced ability to exercise, decreased quality of life, and, eventually, increased mortality. Home oxygen therapy in patients with severe COPD reduces distress symptoms and mortality rates. However, there have been few studies on physicians’ prescription behavior toward home oxygen therapy. Therefore, we investigated the respiratory specialists’ perspective on home oxygen therapy.MethodsIn this cross-sectional, study, a questionnaire was completed by 30 pulmonary specialists who worked in tertiary hospitals and prescribed home oxygen therapy. The questionnaire consisted of 28 items, including 15 items on oxygen prescription for outpatients, four for inpatients, and nine on service improvement.ResultsAll physicians were prescribing less than 2 L/min of oxygen for either 24 (n = 10, 33.3%) or 15 hours (n = 9, 30.3%). All (n = 30) used pulse oximetry, 26 (86.7%) analyzed arterial blood gas. Thirteen physicians had imposed restrictions and recommended oxygen use only during exercise or sleep. Sixteen (53.3%) physicians were educating their patients about home oxygen therapy. Furthermore, physicians prescribed home oxygen to patients that did not fit the typical criteria for long-term oxygen therapy, with 30 prescribing it for acute relief and 17 for patients with borderline hypoxemia.ConclusionsThis study identified the prescription pattern of home oxygen therapy in Korea. Respiratory physicians prescribe home oxygen therapy to hypoxemic COPD patients for at least 15 hours/day, and at a rate of less than 2 L/min. More research is needed to provide evidence for establishing policies on oxygen therapy in COPD patients.

Prescription of Lipid-Lowering and Antihypertensive Drugs Following Pictorial Information About Subclinical Atherosclerosis

Preventive drugs are often underused. Carotid intima-media thickness and carotid plaques are associated with cardiovascular disease (CVD), and their detection could possibly improve estimation of the likelihood of CVD and prescription of preventive drugs. To evaluate whether pictorial information on participants' asymptomatic atherosclerosis based on carotid ultrasonographic examinations to participants and their physicians had an effect on prescribing of lipid-lowering or antihypertensive drugs during the following 465 days. Visualization of Asymptomatic Atherosclerotic Disease for Optimum Cardiovascular Prevention is a pragmatic randomized clinical trial nested within the Västerbotten Intervention Program, a CVD screening and prevention program in Sweden with 60% to 70% participation rates and small social selection bias. A total of 4177 individuals aged 40, 50, or 60 years participating in the Västerbotten Intervention Program who had low to moderate risk of CVD were invited to enroll in this trial from April 29, 2013, to June 7, 2016. Prescriptions for all participants were monitored for 465 days after the intervention. Data analysis was conducted from December 6, 2019, to April 2, 2020. Participants and their family physicians were randomly assigned 1:1 to receive or not receive pictorial information from carotid ultrasonographic determination of vascular age, assessed as carotid intima-media thickness and the presence of carotid plaques, combined with a follow-up call to participants by nurses. Two outcome measures of prescriptions of antihypertensive and lipid-lowering drugs within 465 days after ultrasonography was performed. Data obtained through intention-to-treat analysis are presented as proportions of individuals with a prescription among those who had no baseline prescription for agents from these drug classes. Of the 4177 individuals invited to enroll, 3532 participants were randomized and included in the analysis; 1870 (52.9%) were women, 2278 (64.5%) were aged 60 years, 978 (27.7%) were 50 years, and 276 (7.8%) were 40 years. First prescriptions of lipid-lowering drugs were higher in the intervention group vs the control group among men (118 of 639 [18.5%] vs 38 of 692 [5.5%]; P < .001) and women (126 of 804 [15.5%] vs 38 of 817 [4.7%]; P < .001). There were no significant differences in the proportion with prescription of antihypertensive drugs in the intervention vs control groups after ultrasonography among men (58 of 482 [12.0%] vs 56 of 528 [10.6%]; P = .47) and women (60 of 612 [9.8%] vs 64 of 615 [10.4%]; P = .73). The findings of this trial demonstrate that provision of pictorial information on vascular age and carotid plaques based on the results of ultrasonographic examination increased physician prescription of lipid-lowering drugs but not antihypertensive drugs within the following 465 days. ClinicalTrials.gov Identifier: NCT01849575.

27534 Physician-patient knowledge on GoodRx

Background: GoodRx is a popular free-to-use website and mobile application used by physicians and patients to locate the cheapest available drug prices in a nearby pharmacy. GoodRx claims to gather current prices and discounts to find the lowest cost retail pharmacy for all available prescriptions. We sought to assess the impact of GoodRx on physician and patient prescription practices and to confirm the accuracy of GoodRx on identifying the cheapest drug prices in a metropolitan area.

Factors affecting physician implementation of hospital pharmacists' medication appropriateness recommendations in older adults.

Non-implementation of pharmacist recommendations by physician prescribers may prolong potentially inappropriate prescribing in hospitalised older adults, increasing the risk of adverse clinical outcomes. The aim of this study was to ascertain the key factors affecting physician prescriber implementation of pharmacists' medication appropriateness recommendations in hospitalised older adults. Semi-structured interviews were conducted with hospital pharmacists and physicians who provided care to older adults (≥65 years) in 2 acute university teaching hospitals in Ireland. Content analysis was employed to identify the key themes that influence physician prescriber implementation of pharmacist recommendations. Fourteen interviews were conducted with 6 hospital pharmacists and 8 hospital physicians between August 2018 and August 2019. Five key factors were found to affect physician implementation of pharmacist recommendations: (i) the clinical relevance and complexity of the recommendation-recommendations of higher priority and those that do not require complex decision-making are implemented more readily; (ii) interprofessional communication-recommendations provided verbally, particularly those communicated face to face with confidence and assertion, are more likely to be implemented than written recommendations; (iii) physician role and identity-the grade, specialty, and personality of the physician significantly affect implementation; (iv) knowing each other and developing trusting relationships-personal acquaintance and the development of interprofessional trust and rapport greatly facilitate recommendation implementation; and (v) the hospital environment-organisational issues such as documentation in the patient notes, having the opportunity to intervene, and the clinical pharmacy model all affect implementation. This study provides a deeper understanding of the underlying behavioural determinants affecting physician prescriber implementation of pharmacist recommendations and will aid in the development of theoretically-informed interventions to improve medication appropriateness in hospitalised older adults.

Short term physician visits and medication prescriptions for allergic disease associated with seasonal tree, grass, and weed pollen exposure across the United States

BackgroundWhile year-round exposure to pollen is linked to a large burden of allergic diseases, location-specific risk information on pollen types and allergy outcomes are limited. We characterize the relationship between acute exposure to tree, grass and weed pollen taxa and two allergy outcomes (allergic rhinitis physician visit and prescription allergy medication fill) across 28 metropolitan statistical areas (MSA) in the United States.MethodsWe obtained daily pollen data from National Allergy Bureau (NAB) monitors at these 28 MSAs for 2008–2015. We revised the NAB guidelines to classify taxa-specific pollen severity each day. Daily information on allergic rhinitis and prescribed allergy medications for individuals with employer-based health insurance from the IBM MarketScan Research database for these MSAs. We combined the daily pollen and health data for each MSA into a longitudinal dataset. We conducted a MSA-specific conditional quasi-Poisson regression analysis to assess how different levels of pollen concentration impact the health outcomes, controlling for local air pollution, meteorology and Influenza-like illness (ILI). We used a random effects meta-analysis to produce an overall risk estimate for each pollen type and health outcome.ResultsThe seasonal distribution of pollen taxa and associated health impacts varied across the MSAs. Relative risk of allergic rhinitis visits increased as concentrations increased for all pollen types; relative risk of medication fills increased for tree and weed pollen only. We observed an increase in health risk even on days with moderate levels of pollen concentration. 7-day average concentration of pollen had stronger association with the health outcomes compared to the same-day measure. Controlling for air pollution and ILI had little impact on effect estimates.ConclusionThis analysis expands the catalogue of associations between different pollen taxa and allergy-related outcomes across multiple MSAs. The effect estimates we present can be used to project the burden of allergic disease in specific locations in the future as well inform patients with allergies on impending pollen exposure.

The Association between Implementation of an Enhanced Recovery after Cesarean Pathway with Standardized Discharge Prescriptions and Opioid Use and Pain Experience after Cesarean Delivery.

This study was aimed to evaluate opioid use after cesarean delivery (CD) and to assess implementation of an enhanced recovery after CD (ERAS-CD) pathway and its association with inpatient and postdischarge pain control and opioid use. We conducted a baseline survey of women who underwent CD from January to March 2017 at a single, urban academic hospital. Patients were called 5 to 8 days after discharge and asked about their pain and postdischarge opioid use. An ERAS-CD pathway was implemented as a quality improvement initiative, including use of nonopioid analgesia and standardization of opioid discharge prescriptions to ≤25 tablets of oxycodone of 5 mg. From November to January 2019, a postimplementation survey was conducted to assess the association between this initiative and patients' pain control and postoperative opioid use, both inpatient and postdischarge. Data were obtained from 152 women preimplementation (PRE) and 137 women post-implementation (POST); complete survey data were obtained from 102 women PRE and 98 women POST. The median inpatient morphine milligram equivalents consumed per patient decreased significantly from 141 [range: 90-195] PRE to 114 [range: 45-168] POST (p = 0.002). On a 0- to 10-point scale, median patient-reported pain scores at discharge decreased significantly (PRE: 7 [range: 5-8] vs. POST 5 [range: 3-7], p < 0.001). The median number of pills consumed after discharge also decreased significantly (PRE: 25 [range: 16-30] vs. POST 17.5 [range: 4-25], p = 0.001). The number of pills consumed was significantly associated with number prescribed (p < 0.001). The median number of leftover pills and number of refills did not significantly differ between groups. Median patient-reported pain scores at the week after discharge were lower in the POST group (PRE: 4 [range: 2-6] vs. POST 3[range: 1-5], p = 0.03). Implementing an ERAS-CD pathway was associated with a significant decrease in inpatient and postdischarge opioid consumption while improving pain control. Our data suggest that even fewer pills could be prescribed for some patients. · An ERAS-CD pathway was associated with decreased opioid use.. · Outpatient opioid consumption after cesarean warrants further study.. · Physician prescribing drives patients' opioid consumption..

Stakeholder point of view on prescription drug affordability - a systematic literature review and content analysis

ObjectivesThe objectives of this research were to: 1) understand perspectives on affordability of pharmaceutical drugs from the point of view of stakeholders as reported in published peer-reviewed journals and conferences; 2) evaluate if (and how) perspectives on affordability overlapped across stakeholders. MethodsThe systematic literature review followed Cochrane and PRISMA guidelines. Content analysis with iterative and systematic coding of text was conducted, to identify themes. ResultsA total of 7,372 unique citations were eligible, and 126 articles included for final synthesis. For patients, 6 core themes emerged: financial barriers, adherence, access, patient-provider communication, financial distress, and factors that impact affordability. For payers, 5 core themes: financing schemes, cost-effectiveness, budget impact, private vs. public preferences, and ethics. For providers, 3 themes: patient-provider communication, physician prescribing behavior, and finding alternatives to support patient access. For policymakers, 2 themes: measuring affordability and the role of government. Limited articles representing the manufacturer perspective were identified. Perspectives of decision makers (payers, policymakers) did not overlap with those affected by affordability (patients, providers). ConclusionsThis research highlights the multi-dimensionality of drug “affordability.” Multiple factors beyond cost influence patient affordability implying interventions can help alleviate affordability issues for some patients. The lack of overlap highlights potential hazards that decisions related to out-of-pocket spending, insurance coverage, reimbursement, and rationing occur without explicitly considering patient and provider perspectives.

The COVID-19 Pandemic and Antibiotic Use on the United States–Mexico Border

Background: The US–Mexico border represents a unique region of the country where antibiotics are more accessible and nonprescription treatment with antibiotics is deeply enculturated. Currently, both the United States and Mexico are experiencing widespread community transmission of SARS-CoV-2, which may have implications for antibiotic seeking and use. The objective of this study was to examine antibiotic seeking behavior as it relates to COVID-19 in the border region relative to the greater US and Mexico populations. Methods: An interdisciplinary team at The University of Arizona developed a survey to assess knowledge, attitudes, and beliefs about antibiotics along the US–Mexico border region (defined as 100 km from the border) and to compare findings from the border region to the broader US and Mexico populations. The team recruited survey participants through Amazon’s MTurk survey platform and through the distribution of recruitment flyers to community partners in Arizona and Mexico border regions from October 2020 to January 2021. Targeted recruitment was 750 through March 2021. We report here on findings from the first round of recruitment (n = 116). These participants were asked whether they had sought out antibiotics specifically as a treatment for COVID-19, as well as their general beliefs and behaviors on self-seeking antibiotics for illness. Results: As of January 24, 2021, we surveyed 116 participants: 82 (70.7%) from the United States and 34 (29.3%) from Mexico. Most participants (71.2%) were aged 25–44 years; 56.9% were male; and 50% reported Hispanic ethnicity. Of these, 13.8% lived within 100 km of the US–Mexico border. Overall, 21.6% of participants reported taking antibiotics to fight COVID-19–like illness. Of these participants, 28% obtained the antibiotics directly from a pharmacy, without a physician prescription, and 16% obtained them from an online vendor. Additionally, 33% of US respondents reported that they would be willing to travel to Mexico to obtain antibiotics if they were too difficult to obtain in the United States. Of these respondents, 55% said they would be willing to travel for &gt;1 hour to obtain antibiotics. Conclusions: Preliminary data suggest that the COVID-19 pandemic will have widespread ramifications on antibiotic seeking behavior and could propagate antibiotic resistance. Targeted intervention strategies in the border region are necessary to mitigate the unique factors that contribute to antibiotic use in this area.Funding: NoDisclosures: None

The Status of Potentially Inappropriate Medication Prescription by General Physicians for The Elderly in Tabriz (Iran) According to Beers Criteria

Objectives: Prescribing medication for the elderly is an important health issue. This study aimed to investigate the status of Potentially Inappropriate Medications (PIMs) prescription for the elderly by general physicians in Tabriz, Iran. Methods &amp; Materials: This descriptive cross-sectional study was conducted in 2019 on the prescriptions of general physicians for the elderly in Tabriz, Iran. After initial screening of 16842 prescriptions belonged to two insurance systems (social security insurance and health insurance), 1500 prescriptions were selected. The Beers criteria 2019 was used to assess PIM prescription status and their alternatives were suggested if needed. Data were expressed as Mean±Standard Deviation (SD) and No. (%), and analyzed in SPSS v. 21 software. The Mann-Whitney U test was used to examine the differences in the study factors between the prescriptions related to two insurance systems. The relationship between patients’ age and PIM prescription was examined using Spearman correlation test. Results: The Mean±SD number of drugs in each prescription was 3.93±1.5 and the Mean±SD number of prescribed PIMs was 0.74±0.8. Polypharmacy was observed in 32.6% of the prescriptions, and 53.9% had at least one PIM. Non-steroidal anti-inflammatory drugs, antihistamines and benzodiazepines were the most PIM groups (45.6, 10.9 and 10.6%, respectively). The most common prescribed PIMs were Adult cold, Diclofenac, Glibenclamide, Ketorolac and Diphenhydramine. Number of PIMs in each prescription did were not statistically different between the prescriptions related to two insurance systems (P=0.343). Moreover, patients’ age and gender had no significant relationship with PIM prescription (P=0.312 and P=0.660, respectively). Conclusion: About 54% of the prescriptions issued by general physicians for the elderly in Tabriz contain PIMs, and polypharmacy is present in about one third of the prescriptions. In order to improve this condition, it is necessary to hold appropriate training and continuous retraining courses in geriatric medicine for general physicians. Supervisions by the Iranian Ministry of Health and Iranian Medical Council can also play an important role in improving the current situation.

Antibiotic Prescribing in Outpatient Before and After Implementation of the Urban Family Physician and Referral System

Background The Family Physician and Referral System was piloted in Mazandaran and Fars provinces, Iran in 2012. The goal of this program was to improve the provision of health services including medication prescription. Objective This study aimed to determine the trends in antibiotic prescribing in outpatient before and after implementation of the Family Physician and Referral System in Babol, Iran from 2010 to 2018. Methods In this retrospective study, all prescriptions of urban family physicians in Babol, which were registered in the database of the Health Services Insurance Organization of Mazandaran province, were included. The trends of average number of items per prescription, percentage of antibiotics per prescription, frequency of antibiotic groups, and cost of antibiotics were calculated using SQL Server and IBM SPSS version 22. Results The average number of items per prescription was found to be 3.4±1.82, and 2.8±1.60, and percentage of antibiotics per prescription was 49% and 32% in 2010 and 2018, respectively. The most prescribed antibiotic groups were penicillin (54.8%) and cephalosporin (39.9%). Amoxicillin 500mg capsules (13.1%), metronidazole 250 mg (10.2%), and ciprofloxacin 500 mg (8.2%) were the most prescribed antibiotics. Also, the mean cost of prescriptions containing antibiotics compared to the total prescriptions had decreased from 22% in 2010 to 5.5% in 2018. Conclusion The pattern of medication prescription especially antibiotics, improved after the implementation of the Family Physician and Referral System. Due to the positive impact of the Family Physician and Referral System on medication prescription by physicians, we recommend the implementation of this program in low and middle-income countries. Keywords: Antibiotic, medication prescribing, Health system reform plan, Family physician, Trend

Adjuvant endocrine therapy for premenopausal women with breast cancer: Patient adherence and physician prescribing practices in Mexico

BackgroundIn resource-constrained settings, data regarding breast cancer patients' adherence to endocrine therapy (ET) and physicians’ prescribing practices is limited. This study aims to decrease this knowledge gap in a real-world clinical practice. MethodsPremenopausal women with stage 0-III hormone-sensitive breast cancer and receiving adjuvant ET during the past 1–5 years were identified in three Mexican referral centers. Participants' self-reported ET compliance, clinicopathologic characteristics, ET-related knowledge and beliefs, experienced adverse effects, social support, and patient-physician relationships were evaluated. Physician ET prescribing practices were compared with the gold standard according to international and national guidelines to assess clinicians’ adherence to standard-of-care prescription. ResultsIn total, 95/132 (72%) and 35/132 (27%) participants reported complete and acceptable adherence, respectively. Incomplete adherence was mainly attributed to forgetfulness, adverse effects, and unwillingness to take ET. Being employed/studying (p = 0.042), worrying about long-term ET use (p = 0.031), and experiencing >7 ET-related symptoms (p = 0.018) were associated with incomplete adherence. Guideline-endorsed regimens were prescribed in 84/132 (64%) patients, while the rest should have undergone ovarian function suppression (OFS) but instead received tamoxifen monotherapy. ConclusionsPremenopausal Mexican women self-report remarkably high rates of adequate ET adherence. However, a considerable proportion misses ≥1 doses/month, usually because of forgetfulness. Notably, only 64% receive standard-of-care ET due to suboptimal prescription of OFS. Interventions that remind patients to take their ET, refine physicians’ knowledge on the importance of OFS in high-risk patients, and increase access to OFS could prove pivotal to enhance optimal ET implementation and adherence, which could translate into improved patient outcomes.

Opioid and non-opioid analgesic prescribing before and after the CDC's 2016 opioid guideline.

The U.S. has addressed the opioid crisis using a two-front approach: state regulations limiting opioid prescriptions for acute pain patients, and voluntary federal CDC guidelines on shifting chronic pain patients to lower opioid doses and non-opioids. No opioid policy research to date has accounted for this two-pronged approach in their research design. We develop a theory of physician prescribing behavior under this two-pronged incentive structure. Using the Medical Expenditure Panel Survey, we empirically corroborate the theory: regulations and guidelines have the intended effects of reducing opioid prescriptions for acute and chronic pain, respectively, as well as the predicted unintended effects—income effects cause regulations on acute pain treatment to increase chronic pain opioid prescriptions and the chronic pain treatment guidelines spillover to reduce opioids for acute pain. Moreover, we find that the guidelines worked as intended in terms of the reduced usage, with chronic pain patients shifting to non-opioids and also tapering opioid doses. For those who discontinued opioids under regulations and guidelines, we find no harm in terms of increased work limitations due to pain a year after discontinuing opioids. Finally, we observe an unexplained dichotomy—regulations reduce opioid use by causing fewer new starts, whereas guidelines reduce opioid use by discontinuing current users, with no impact on new starts.

PRESCRIPTION AUDIT IN OUTPATIENT DEPARTMENTS OF TERTIARY CARE HOSPITALS; FACTS AND RECOMMENDATIONS

Objective: To evaluate written prescriptions according to a checklist based on WHO guidelines (prescription audit). To compare prescriptions of senior and junior physicians and to provide data and recommendations.&#x0D; Study Design: Cross-sectional, analytic study.&#x0D; Place and Duration of Study: Pak Emirates Military Hospital, and Combined Military Hospital, Rawalpindi Pakistan, from March to Aug 2018.&#x0D; Methodology: A total of 205 prescriptions using convenient sampling technique were analyzed according to a checklist based on WHO guidelines for standard prescription writing. Data was analyzed using SPSS-22.&#x0D; Results: Out of total 205 prescriptions, 83 (40%) prescriptions belong to senior and 122 (60%) to junior physicians. Fifty (25%) prescriptions lacked patient name, 49 (24%) lacked age. Gender was mentioned in only 117 (57%) prescriptions. Date, diagnosis and dosage of drug were written in 170 (83%), 172 (84%) and 177 (86%) respectively while dosage form and route of administration were mentioned in 144 (70%) and 102 (50%) respectively. Generic name was written in only 75 (37%) prescriptions. Name and stamp of the doctor were available on 135 (66%) and 125 (61%) prescriptions respectively. A statistically significant association was observed between senior and junior physicians in terms of error in name of patient and dosage form (p=0.002&amp; 0.005 respectively).&#x0D; Conclusions: Prescriptions were mainly deficient in the generic names of drugs. Route of administration was missing in half of the prescriptions. None of the parameters was totally accurate. Prescriptions from junior physicians had more errors.

Current prescribing practices and guideline concordance for the treatment of uncomplicated urinary tract infections in women

Uncomplicated urinary tract infections are one of the most common bacterial infections in the United States. Clinical practice guidelines from the Infectious Diseases Society of America recommend nitrofurantoin, trimethoprim-sulfamethoxazole, and Fosfomycin as first-line antibiotic treatments and discourage the use of fluoroquinolone antibiotic agents. US Food and Drug Administration released several black box warnings about fluoroquinolones over the past decade owing to antibiotic resistance and a high burden of adverse events. Historically, uncomplicated urinary tract infections have high rates of guideline-discordant treatment with past studies noting substantial use of fluoroquinolones, directly contradicting clinical practice guidelines. This study aimed to assess the current concordance of physician prescribing practices with Infectious Diseases Society of America guidelines for the treatment of uncomplicated urinary tract infections in women and identify patient and physician predictors of guideline concordance. A retrospective observational secondary analysis was conducted using a series of cross-sectional data extracted from the IQVIA (Plymouth Meeting, Pennsylvania) National Disease and Therapeutic Index from 2015 to 2019. An estimated 44.9 million women with uncomplicated urinary tract infections at the age of 18 to 75 years were treated as outpatients. This population was selected to lack relevant comorbidities or urological abnormalities so that it matched the Infectious Diseases Society of America guidelines. The proportion of prescriptions for each antibiotic drug class were reported with 95% confidence intervals and compared with the Infectious Diseases Society of America guidelines. Patient and physician characteristics were included in a multivariate logistic regression model to identify independent predictors of antibiotic selection and thereby guideline concordance. Of the visits that resulted in antibiotic treatment, the overall concordance rate was 58.4% (26.2 million visits of 44.9 million visits) and increased from 48.2% (3.9 million visits of 8.1 million visits) in 2015 to 64.6% (6.3 million visits of 9.8 million visits) in 2019. The most commonly prescribed antibiotic agents were fluoroquinolones (36.4%, 16.3 million visits of 44.9 million visits), nitrofurantoin (31.8%, 14.3 million visits of 44.9 million visits), and trimethoprim-sulfamethoxazole (26.3%, 11.8 million visits of 44.9 million visits). From 2015 to 2019, fluoroquinolone use decreased whereas nitrofurantoin and beta-lactam use increased. Based on the logistic regression, patients aged 18 to 29 years (odds ratio, 1.60; 95% confidence interval, 1.36-1.88; P<.001) and 30 to 44 years (odds ratio, 1.21; 95% confidence interval, 1.03-1.42; P=.020) had a statistically significantly higher likelihood of receiving guideline-concordant treatment than patients aged 45 to 75 years (reference group). Obstetricians-gynecologists (odds ratio, 3.56; 95% confidence interval, 2.91-4.37; P<.001) and urologists (odds ratio, 3.51; 95% confidence interval, 2.45-5.13; P<.001) had a statistically significantly higher likelihood of concordant treatment than all other specialties combined (reference group). Guideline discordance continues in the treatment of uncomplicated urinary tract infections with the overuse of fluoroquinolones and the underuse of first-line antibiotic agents. Although improving, continued misuse of antibiotic agents may contribute to the growing rates of antibiotic resistance. Actions such as educating physicians about antibiotic resistance and clinical practice guidelines and providing feedback on prescription habits are needed to increase guideline concordance and therefore reduce the use of fluoroquinolones, especially for physicians in family and internal medicine.

Industry payments and physicians prescriptions: Effect of a payment restriction policy

The pharmaceutical industry spends billions of dollars every year for marketing its products to US health care providers. This study investigates the association between industry marketing payments and physicians’ prescription in New York and Massachusetts, and examines the effect of the Massachusetts payment restriction policy on this association in comparison with the New York State that has no payment restriction policy.Three panel data models (fixed effects regression (FE), first difference regression (FD), and first difference with lagged independent variable (LFD)) were used to establish the association accounting for unobserved confounders and reverse causality. The main indicator is the total amount of industry payments for meals, drug samples, consulting fees, etc. (excluding research funding, and ownership). Dependent variables are a) yearly days’ supply of Medicare Part D prescriptions, b) yearly costs of prescribed prescriptions. Secular time trends, as well as differences between the two states were controlled in all models.All three panel models showed significant positive association between industry payments and physician prescriptions. Particularly, these models show that in the base year (2014), a 1% increase in the annual industry payments was associated with (0.01%–0.04%) increase in days' supply of medication, and (0.01%–0.05%) increase in prescription costs for NYS providers. Moreover, FE and FD models show that compared to NYS physicians, the association of industry payments with days’ supply and costs of Medicare Part D prescriptions was (0.01%–0.02%) smaller for MA physicians. Because of the smaller sample size and lower power, the LFD model did not detect a significant difference between the NYS and MA providers.The findings of this study provide additional evidence that industry payments are associated with increases in the volume and cost of Medicare prescriptions. Moreover, these findings provide preliminary evidence that payment restriction policies negatively moderate this association, which calls for further research.