Physician Prescribing Research Articles

Barriers and facilitators for pharmacists prescribing emergency contraception under statewide protocol

AbstractBackgroundPharmacists can prescribe levonorgestrel and ulipristal acetate emergency contraception (EC) under statewide protocol in California. The objective of this study was to determine barriers and facilitators for pharmacists prescribing EC.MethodsFor this qualitative study, we conducted semi‐structured individual interviews with 18 pharmacists and pharmacy technicians practicing in pharmacies across California. We operationalized the Practical, Robust Implementation and Sustainability Model (PRISM) implementation science framework to develop the interview guide and inform the thematic analysis. The interview questions explored barriers and facilitators to implementation of pharmacist prescribing of EC.ResultsSeveral themes emerged around barriers and facilitators to service implementation in the PRISM domains of Intervention, External Environment, Implementation and Sustainability Infrastructure, and Recipients. Though participants had experience with over‐the‐counter sales of levonorgestrel EC, they had limited experience prescribing EC and with ulipristal acetate. Reported barriers include difficulty incorporating an additional service into workload without payment or additional human resources, lack of patient demand possibly due to absence of public awareness, lack of physician prescribing of EC, management approval required, and being unaware of the protocol. Participating pharmacists reported being motivated to prescribe EC to benefit patients and provide clinical services. Other reported facilitators included support from their local communities, opportunities created by the statewide protocol, training opportunities, pharmacy team‐based care, and providing patient‐centered care.ConclusionsMultilevel contextual barriers and facilitators exist to implementing pharmacist prescribing of EC that could be addressed in a multicomponent implementation intervention. These findings may help guide implementation strategies, thus increasing patient access to EC.

Estimation of the cost of influenza antiviral medication guidance or support provided by healthcare professionals: a questionnaire survey in Japan

Aims To estimate the cost of antiviral medication guidance and/or support from the perspective of healthcare professionals by administration route (oral or inhalant). Methods An online survey (December 2020) was conducted among physicians, pharmacists, and certified care workers. Those aged 20–64 years working in workplaces with experience of prescribing (physicians) or dispensing (pharmacists) antivirals for influenza, or having care service recipients who took antivirals (certified care workers) since October 2018, were selected through screening questions. The time required for guidance and/or support for drug administration was asked, and its monetary value was calculated by applying the Japanese average wage. Respondents who had a fear of infection while providing guidance and/or support were asked about the monetary value of this fear; the cost of fear was estimated from their responses and the percentage who reported such a fear. Results Responses were collected from 1,000 physicians, 1,000 pharmacists, and 642 certified care workers. The cost of the time for guidance and/or support in the entire workplace was estimated as JPY 244 (USD 2.14, as of October 2021) for oral antivirals and JPY 289 for inhalants among physicians, JPY 260 and JPY 428 among pharmacists, and JPY 555 and JPY 557 among certified care workers. The cost of fear was estimated to be JPY 965 for oral and JPY 1,361 for inhalants among physicians, JPY 756 and JPY 2,711 among pharmacists, and JPY 2,419 and JPY 2,837 among certified care workers. Limitations Respondents might not be representative of Japanese society. The reliability of the results depends on whether the respondents accurately understood the questions and their truthfulness. Conclusions Higher costs for guidance and/or support were suggested for inhalant antivirals in physicians and pharmacists compared to oral antivirals. For certified care workers, almost no difference in costs was suggested between administration routes.

Impact of Nurse-Led Titration Versus Physician Prescription of Hypoglycaemic Agents on HbA1c Level in Type 2 Diabetes Patients: A Systematic Review and Meta-Analysis of Randomized Controlled Trials.

A nurse-led diabetic clinic to manage type 2 diabetes, which emphasizes medication adherence, titration of hypoglycemic agents, behavior modification, and motivation for lifestyle changes, is widely recommended and practiced in western countries.This review aims to examine the impact of a nurse-led diabetic clinic versus a standard physician-led diabetic clinic on glycaemic control of type 2 diabetes patients.Studies were obtained using a comprehensive search in the electronic databases of PubMed, Embase, SCOPUS, Cochrane Library, and gray literature through March 2021. We calculated the pooled effect estimate with 95% confidence intervals (CIs) comparing subjects with and without nurse-led titration of hypoglycemic agents using standardized mean difference (SMD) for continuous outcomes and risk ratio (RR) for dichotomous outcomes.Four trials comprising 470 participants (241 intervention group and 229 control group) met the inclusion criteria. Glycated hemoglobin (HbA1c levels and BMI were lower in participants with a nurse-led diabetic clinic (SMD = -0.54, 95% CI -0.89 to -0.20, I2 = 67%, p = 0.002) and (SMD = -0.26 (95% CI -0.45 to -0.07, I2 = 0%, p = .008), respectively, than in those attending a standard physician-led diabetic clinic. Similarly, the pooled result shown that patients attending the nurse-led diabetic clinic had a 31% higher satisfaction level (RR 0.69; 95% CI, 0.51 to 0.92, I2 = 0%, p= 0.01). On the other hand, there was no significant association of the nurse-led diabetic clinics on patients’ blood pressure and intensification of hypoglycemic agents. The certainty of the evidence assessed using Grading of Recommendations Assessment, Development, and Evaluation (GRADE) was moderate for outcomes like HbA1c level, intensification of hypoglycemic agents, and patients' satisfaction and low for other secondary outcomes.Our meta-analysis allows for the conclusion that nurse-led titration of hypoglycemic agents is associated with better glycemic control and enhances patients' satisfaction. Therefore, it is recommended to establish and strengthen nurses-led diabetic clinics for better HbA1c control where physician-led diabetic services are limited. Further research is needed to enhance the quality of the evidence.

The Use and Potential Interactions of Herbal Medicines among Diabetic Patients in Saudi Arabia: A Cross-sectional Study

Objectives: The use of herbal medicines as non-conventional treatment is popular, especially in developing countries where people suffering from chronic diseases as diabetes mellitus are more likely to use herbal medicines along with conventional medicines. However, their simultaneous use may concur serious drug interactions and may therefore result in a serious outcome. The present study was designed to identify the most commonly used herbal medicines and conventional anti-diabetic medications among Saudi population.
 Methods: A cross-sectional survey was developed and piloted.Data were retrieved and manually entered in Excel 2016. Frequencies and percentages were utilized to perform descriptive analysis. The study was approved by the Scientific and Research Committee of the main hospital taking part in the study.
 Results: A total of 347 responses were recorded (69.4% response rate). 54% of participants were male, 53% were between the age of 41 and 64 years, and 35.5% had no formal education. Black tea, Peppermint, ginger, green tea, olive oil, and black seed were among the frequently mentioned herbal medicines. Black tea was used by the majority of patients (80%) while peppermint and ginger were used by more than half of patients, i.e., (56.5%) and (52.7%) respectively. Least common herb used by patients was Artemisia species (2.8%). A majority of patients (53.4%) used traditional medicine at least once daily, and 83% used traditional medicine without their physician's prescription.
 Conclusion: Concomitant use of herbal and conventional anti-diabetic medication was a common practice among patients in Saudi Arabia, therefore, pharmacists-led educational programs should target both prescribers and general public about the possible interactions/risks of herbal medicines.

Printed educational materials directed at Ontario family physicians do not improve adherence to guideline recommendations for diabetes management: a pragmatic, factorial, cluster randomized controlled trial [ISRCTN72772651

BackgroundPrinted educational materials (PEMs) have long been used to inform clinicians on evidence-based practices. However, the evidence for their effects on patient care and outcomes is unclear. In Ontario, despite widely available clinical practice guidelines recommending antihypertensives and cholesterol-lowering agents for patients with diabetes, prescriptions remain low. We aimed to determine whether PEMs can influence physicians to intensify prescribing of these medications.MethodsA pragmatic, 2 × 2 factorial, cluster randomized controlled trial was designed to ascertain the effect of two PEM formats on physician prescribing: a postcard-sized message (“outsert”) or a longer narrative article (“insert”). Ontario family physician practices (clusters) were randomly allocated to receive the insert, outsert, both or neither. Physicians were eligible if they were in active practice and their patients were included if they were over 65 years with a diabetes diagnosis; both were unaware of the trial. Administrative databases at ICES (formerly the Institute for Clinical Evaluative Sciences) were used to link patients to their physician and to analyse prescribing patterns at baseline and 1 year following PEM mailout. The primary outcome was intensification defined as the addition of a new antihypertensive or cholesterol-lowering agent, or dose increase of a current drug, measured at the patient level. Analyses were by intention-to-treat and accounted for the clustering of patients to physicians.ResultsWe randomly assigned 4231 practices (39% of Ontario family physicians) with a total population of 185,526 patients (20% of patients with diabetes in Ontario primary care) to receive the insert, outsert, both, and neither; among these, 4118 practices were analysed (n = 1025, n = 1037, n = 1031, n = 1025, respectively). No significant treatment effect was found for the outsert (odds ratio (OR) 1.01, 95% confidence interval (CI) 0.98 to 1.04) or the insert (OR 0.99, 95% CI 0.96 to 1.02). Percent of intensification in the four arms was similar (approximately 46%). Adjustment for physician characteristics (e.g., age, sex, practice location) had no impact on these findings.ConclusionsPEMs have no effect on physician’s adherence to recommendations for the management of diabetes-related complications in Ontario. Further research should investigate the effect of other strategies to narrow this evidence-to-practice gap.Trial registrationISRCTN72772651. Retrospectively registered 21 July 2005.

Personal & Professional Qualities of Medical Representative and Impact on Doctor's Prescribing Behavior

Background: The promotion of a pharmaceutical product is based on the effective collaboration between medical representatives (MR) & physicians. Pharmaceutical companies are following many doctor-consulting strategies and have found a way to promote their products through MR. But it's only possible if the MR communicates the brand's benefit effectively to the doctor. Aims and Objectives: To identify the personal and professional qualities of MRs that affect doctors' prescribing behavior. The impact of three variables like product detailing of MR, MR's attire, and MR's knowledge has been measured on doctor's prescription behavior. Methodology: Three personal and/or professional qualities of MR have been identified (effective detailing, personal attire, and scientific knowledge of MRs) and studied the influence of these qualities on physician's prescribing habits. Responses were collected through self-administered questionnaires from general practitioners, physicians, gynecologists, pediatricians, and dentists. ANOVA & regression analysis models were used to analyze the hypothesis. Result: Eighty-seven percent of the doctors agreed that pharmaceutical companies should train MRs properly about the detailing of brand and product knowledge, 64% of doctors agreed-upon personal attire of MRs attract their attention, and 92% agreed that MR knowledge plays a crucial role in influencing their prescribing behavior. The hypothesis was accepted for detailing, personal attire, and scientific understanding of MRs regarding their influence on doctor's prescription. Conclusion: The role of detailing, personal attire, and scientific knowledge of MR is well established to influence the practice of physicians. Pharmaceutical companies should train their sales team properly, starting from personal grooming to every aspect of brand and therapy for practical in-clinic discussion and doctor conversion.

Capture - recapture based study on the completeness of smear positive pulmonary tuberculosis reporting in southwest Iran during 2016

BackgroundTuberculosis (TB) is one of the ten leading causes of death in infectious diseases and one of the ten leading causes of death in the world. For any TB control program, a valid surveillance is essential. In order to assess the status of the assessment, the quality of the record and the completeness of reporting should be assessed. The purpose of this study was to investigate the completeness of smear positive pulmonary tuberculosis reporting in Ahvaz, south west of Iran.MethodsThis cross-sectional study was conducted in 2016 in Ahvaz, southwest Iran. The study was conducted through a three-source Capture recapture method by collecting laboratory, hospital, physician prescription data; including patient referral to the health care center, prescriptions of patients receiving anti-tuberculosis drugs and prescriptions of medical TB diagnostic laboratories, and laboratory prescriptions. Percentage, mean and standard deviation were used to describe the variables. Data analysis was performed using log-linear model in Rcapture package R software.ResultsGenerally, 134 new cases of smear-positive pulmonary tuberculosis patients were reported through three sources from urban and rural regions during 2016. Pulmonary tuberculosis was reported through three sources from urban and rural regions during 2016. The most common age group was 25 to 44 years and 79.1% of the patient were man. The overall prevalence of new cases of smear-positive pulmonary tuberculosis was in persons that lived urban areas (97.8%). The completeness of reporting the disease estimated by log-linear model was 87.5% and the incidence rate was estimated to be 11.8 disease per 100,000 persons. Completeness of reporting of laboratory, hospital and physician resources were 79%, 30% and 16.3%, respectively.ConclusionsThe present study shows the necessity of evaluating the quality, completeness and linkage between data. Linking between data sources can improve the accuracy and completeness of TB surveillance.

Treatment and Follow-up Care Associated With Patient-Scheduled Primary Care Telemedicine and In-Person Visits in a Large Integrated Health System

Telemedicine visits can offer patients convenient access to a clinician, but it is unclear whether treatment differs from that with in-person visits or how often patients require in-person follow-up. To examine whether physician prescribing and orders differ between telemedicine and office visits, whether physicians conducting telemedicine visits are more likely to require in-person follow-up, and whether telemedicine visits are associated with more health events. This cohort study included all patients who scheduled primary care appointments through the patient portal of a large integrated health care delivery system newly implementing patient-scheduled video telemedicine visits from January 2016 to May 2018. Adjusted rates of any medication prescribed or laboratory tests or imaging ordered and rates of follow-up health care utilization (in-person visits, emergency department visits, and hospitalizations) within 7 days after the index visit, stratified by index primary care visit type, were generated using multivariable adjustment for patient, access, and clinical characteristics. This study included 1 131 722 patients (611 821 [54%] female; mean [SD] age, 43 [22] years) with 2 178 440 total appointments (307 888 [14%] telemedicine), of which 13.5% were for patients younger than 18 years, 22.2% were for patients 65 years or older, and 54.9% were for female patients. After adjustment, 38.6% (95% CI, 38.0%-39.3%) of video visits, 34.7% (95% CI, 34.5%-34.9%) of telephone visits, and 51.9% (95% CI, 51.8%-52.0%) of office visits had any medication prescribed; laboratory tests or imaging were ordered for 29.2% (95% CI, 28.5%-29.8%) of video visits, 27.3% (95% CI, 27.1%-27.5%) of telephone visits, and 59.3% (95% CI, 59.3%-59.4%) of clinic visits. After adjustment, follow-up visits within 7 days occurred after 25.4% (95% CI, 24.7%-26.0%) of video visits, 26.0% (95% CI, 25.9%-26.2%) of telephone visits, and 24.5% (95% CI, 24.5%-24.6%) of office visits. Adjusted emergency department visits and rates of hospitalizations were not statistically significantly different by primary care index visit type. In this cohort study of patient self-scheduled primary care telemedicine visits within ongoing patient-physician relationships, prescribing and orders were significantly lower for telemedicine visits than for clinic visits, with slightly higher follow-up office visits for telemedicine but no difference in health events (emergency department visits or hospitalizations). Video or telephone visits may be a convenient and efficient way to access primary care and address patient needs.

Opioid Prescribing and Utilization Following Isolated Mid-Urethral Sling.

Introduction: Overprescribing by providers is a leading contributor to the opioid crisis. Despite available information regarding the role that physician prescribing plays in the community availability of opioids, guidelines for the management of acute pain remain sparse. This project aims to evaluate opioid prescribing, opioid usage patterns, and postoperative pain control in patients undergoing isolated mid-urethral sling (MUS) placement.Methods: Patients who underwent isolated MUS placement from March 19, 2019 through March 19, 2020 were contacted by telephone in May 2020 and asked a series of questions examining opioid usage, postoperative pain, what they did with unused opioids, and whether they had received education on disposal techniques. A chart review was utilized to determine the amount of opioid prescribed, the presence of any operative complications, and medical and demographic characteristics of subjects.Results: A total of 53 subjects met inclusion criteria, of which 31 participated in a phone interview. Of the 53 subjects, 54.7% received a postoperative opioid prescription, and all but two of these subjects filled their prescription. Of the interviewed subjects, only 66.6% who filled a prescription reported using opioids Fifty percent (n=6) of patients that required oxycodone reported use of four tablets (30 morphine milligram equivalents (MMEs)) or less and used for 1-2 days postoperatively. No patient reported using opioids beyond five days. Only 22.2% reported receiving instruction on opioid disposal, and 16.7% returned unused opioids to a disposal center. 87.1% of subjects rated postoperative pain as “better” or “much better” than expected.Conclusion: Patients undergoing isolated MUS placement require limited amounts of postoperative opioids, if any are needed at all, to achieve satisfactory pain control. Excess prescribed opioids, along with inadequate patient education on proper disposal techniques, may contribute towards opioids that are at risk of diversion for nonmedical use.

Physicians' Opinion Regarding Extended Access to Hormonal Contraception in Switzerland.

(1) Background: Access to hormonal contraceptives (HC) strongly differs between countries and varies from over the counter (OTC) to prescription-only availability. This study aimed to identify opinions among physicians in Switzerland regarding extended access to HC. (2) Methods: Web-based survey among physicians (gynecologists, general practitioners, and pediatricians) in Switzerland. (3) Results: Hundred sixty-three physicians, mainly gynecologists, participated in this survey and 147 (90%) were included for analysis. A total of 68% (n = 100) answered that prescription-only status could be extended under certain conditions but physicians were concerned about patients’ safety (97%, n = 142). Moreover, there was concern about insufficient patient education on HC (93%, n = 136) and that women may forego preventive examinations (80%, n = 118). Participants did not support OTC availability (93%, n = 136). Pharmacists prescribing (including initiation of HC) revealed controversial results, but a combined access model (initial prescription from physician and follow-up prescriptions by pharmacists) found acceptance in 70% (n = 103). (4) Conclusions: Participating physicians stated that prescription-only status for HC could be lifted under certain conditions but also some concerns, e.g., patients’ safety or neglection of preventive examinations, were raised. Future research should focus on specific conditions in which extended access to HC could be agreed on.

P140 - Factors influencing physician prescribing for muscle-invasive urothelial carcinoma in Europe

P140 - Factors influencing physician prescribing for muscle-invasive urothelial carcinoma in Europe

Anti-Inflammatory Drugs and Usage of Them among Saudi Population: Knowledge and Attitude Assessment

Aims: To measure knowledge and attitude among the Saudi population about non-steroidal inflammatory drugs.
 Study Design: This is an observational cross-sectional study.
 Place and Duration of Study: Conducted in the north region of Saudi Arabia between June 2020 and July 2021.
 Methodology: The data collection done by using an electronic questionnaire. Total sample size of 1018 participants, aged between 15-60, Female and Male, agree to participate. Each person meeting the inclusion criteria was provided informed consent, explaining the study aim, and ensuring the confidentiality of information. Data were obtained by filling out the designed Questionnaire.
 Results: A total of 1018 participants completed the survey questionnaire. About 81% of the study participants stated that they have a history of analgesic use without physician prescription in the past six months. More than 30% of participants stated that the pharmacist is the frequent source of recommendation about medication. The most common indication for the participants to use analgesia was headache followed by insomnia.
 Conclusion: The awareness and attitude of the participants to NSAIDs' usage and its complications was not that adequate. Paracetamol was the most usually used analgesic. It must to teach and strengthen the awareness among citizens about the proper method to use NSAIDs.

Characterization of long-term oral anticoagulant adherence trajectories among patients with atrial fibrillation: a retrospective observational study

Abstract Background Medication taking is a dynamic behaviour that changes over time. Conventional adherence summary measures (e.g. proportion days covered) used in the OAC adherence studies conducted so far, however, are insensitive to the fluid nature of adherence. For example, identical PDC values can be calculated for patients with initial good adherence followed by poor adherence, and for those with periodic non-adherence throughout the course of therapy. Purpose The objective of this study was to characterize atrial fibrillation (AF) patients' long-term unique oral anticoagulant (OAC) adherence trajectories. Methods Using linked, population-based administrative data containing physician billings, hospitalization and prescription records of 4.8 million British Columbians (1996–2019), incident adult cases of AF were identified. Only patients who had prescription refill data available for five years were included in the analysis. The primary measure of OAC adherence was the proportion of days covered (PDC) over consecutive 90-day rolling windows. We modelled continuous 90-day PDC values over time. The time variable was number of years since OAC initiation. Group-Based Trajectory Modelling (GBTM) was used to identify patients' unique longitudinal adherence trajectories. To determine the best model, a relative comparison was done between models using Bayesian information criteria (BIC), and the Akaike information criterion (AIC). Results The study cohort was 19,749 AF patients [mean age 70.6y (SD 10.64), 56% male, mean CHA2DS2-VASc score 2.77 (SD 1.39]. The model that best fit our data identified four distinct OAC adherence trajectories (Figure). These were “consistent good adherence” (n=14,631 patients, 74.1% of the cohort), “rapid decline and discontinuation” (n=2327, 11.8%), “rapid decline with recovery” (n=1973, 9.99%), and “slow decline and discontinuation” (n=819, 4.2%). Our results show that there is heterogeneity among non-adherers. PDC dropped significantly in the first year after therapy initiation for those with “rapid decline and discontinuation” trajectory. Patients exhibiting “rapid decline with recovery” also displayed a rapid decline in adherence in the first year but showed improvements around the third year. Those in the “slow decline and discontinuation” trajectory displayed slow decline in adherence over first three years which eventually led to permanent discontinuation of therapy. Conclusion In this retrospective study we distinguished between the different kinds of non-adherence in terms of timing and rate. While a majority of our cohort adhered to their medications, we identified three unique trajectories displaying declining adherence over time at varying rates. Our results emphasize the importance of early intervention and have direct implications for improving the design of adherence interventions. Funding Acknowledgement Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Canadian Institutes of Health Research grant

Comparative adherence between DOAC and VKA in patients with atrial fibrillation: a 23-year retrospective observational study in Canada

Abstract Background A recent systematic review highlighted significant gaps in the evidence on atrial fibrillation (AF) patients' adherence to oral anticoagulants (OAC). Current evidence suffers from short follow-up times, focuses on the first OAC and does not take switching into account. There is also lack of observational data on adherence to warfarin due to its varying dose that complicates the calculations. As such there is lack of evidence on comparative adherence between VKAs and DOACs and whether the convenience of DOACs translates into better adherence in AF patients. Purpose Our objective was to measure AF patients' long-term OAC adherence and compare the impact of taking direct oral anticoagulants (DOAC) versus vitamin K antagonists (VKA) on adherence, while accounting for switching. Methods Using linked, population-based administrative data containing physician billings, hospitalization and prescription records of 4.8 million British Columbians (1996–2019), incident adult cases of AF were identified. The primary measure of adherence was proportion of days covered (PDC). Consecutive rolling 90-day windows were created for each patient starting from their first OAC prescription fill date until the end of their follow-up. The PDC for each 90-day rolling window was calculated and averaged to yield mean adherence over the follow-up period for each patient. Permanent medication discontinuation resulted in a PDC of 0 for all subsequent rolling windows after their supply ran out. As such, both poor execution and non-persistence were measured simultaneously. The association between drug class and adherence was assessed using generalized mixed effect linear regression models with drug class treated as time-varying covariate to account for switching. Results The study cohort was 30,264 AF patients [mean age 72.2 years (SD11.0), 44.6% female, mean CHA2DS2-VASc 2.94 (SD1.4)] with mean follow-up of 7.7 (SD 4.8) years. The mean PDC was 0.71 (SD 0.27) with 51% of the cohort having mean PDC values below the conventional threshold of adherence (PDC<0.8). Adherence dropped over time with the greatest decline in the first two years after therapy initiation. After controlling for all other confounders and accounting for switching, taking VKA compared to DOAC was, on average, associated with a 1-day decrease in number of days of medication-taking per year. Conclusion AF patients' OAC adherence was below the conventional threshold of 0.8, and dropped over time, particularly in the first two years. Drug class had no clinically meaningful impact on medication adherence. Our study highlights the need for effective adherence interventions particularly early in OAC therapy. Our findings also emphasizes that prescribers should not assume inherently better adherence for DOACs and should instead choose OAC in conversation with the patient and in accordance with their values and preferences. Funding Acknowledgement Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Canadian Institutes of Health Research grant

Use of a point-of-care web-based application to enhance adherence to the CANMAT and ISBD 2018 guidelines for the management of bipolar disorder.

While clinical guidelines exist for the management of bipolar disorder (BD), there are significant challenges to their widespread dissemination and implementation in clinical practice. The Canadian Network of Mood and Anxiety Treatment Improving Patient Care and Outcomes in the Treatment of Bipolar Disorder (C-IMPACT BD) web-based application was developed for use at the point-of-care to improve adherence to guidelines for evidence-based pharmacological management of BD. C-IMPACT BD uses a point-of-care practice assessment which, via adaptive questioning of patient-specific information, text/video descriptions of the guidelines, and pop-up prompts delivers personalized, evidence-based treatment recommendations for patients with BD. In order to inform quality improvement of the newly developed tool, a sample of Canadian physicians were invited to use the application and record its influence on their prescribing behavior. Of 375 patients with bipolar I (BD-I) or bipolar II (BD-II) disorder for whom a point-of-care practice assessment was completed, a change in therapy was considered for 225 (60.0%). Prior to completing the assessment, 59.6% of these patients were receiving first-line therapy recommended for their phase of illness. Following the assessment, the overall number of patients for whom a first-line recommended therapy was being considered increased significantly to 76.9% (p=0.0001). Outcomes suggest that the C-IMPACT BD web-based application has the potential to improve physician adherence to clinical treatment guidelines. Formal research investigations are warranted to explore the impact of this tool on physician prescribing behavior and patient outcomes.

Physician Perspectives on Codeine Accessibility, Patterns of Use, Misuse, and Dependence in Saudi Arabia

In Saudi Arabia, there are concerning rates of non-compliance with pharmaceutical regulations prohibiting the pharmacy dispensing of prescription-only medications without a physician prescription. This is the first study in the Middle East which examines physicians’ perceptions regarding misuse of codeine, listed as a narcotic, controlled, and prescription-only drug. The CODEMISUSED survey was adapted to the Saudi Arabian context and pilot tested, prior to cross-sectional administration to physicians in Riyadh, Jeddah, Abha, and Jazan (n = 105). Descriptive statistics (frequencies and percentage) present physician level of agreement, neutrality, and disagreement with statements regarding codeine prescribing, patient awareness and use, online and community pharmacy availability, and dependence. The study indicates concern by physicians regarding patient intentional use of codeine to enhance mood, misuse patterns, lack of awareness around habit-forming use and iatrogenic dependence, and sourcing via illegal dispensing. It underscores the imperatives to address pharmacy compliance with pharmaceutical regulatory controls, implement enhanced pharmacovigilance, and improve awareness around safe use.

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.

43.2 Youth Receiving Opioid Agonist Treatment: Exploring Differences and Similarities to Adult Patients in a Canadian Study

There continues to be an underutilization of opioid agonist treatment (OAT) in youth younger than 25 years. Understanding unique characteristics of this population may inform the treatment goals and supports required to improve treatment for youth with opioid use disorder (OUD). We explored characteristics of youth (ages 16-25 years) enrolled in OAT compared to adults (>25 years). Data were collected from 261 youth and 3184 adults receiving OAT at 36 outpatient clinics in Ontario, Canada. Cross-sectional data on sociodemographic, treatment, and substance use characteristics were obtained at study entry. The Mini-International Neuropsychiatric Interview was administered to patients recruited from 2013 to 2016, including 66 youths and 617 adults, to identify mental illness comorbidity. We used logistic regression to explore characteristics associated with youth compared to adults enrolled in OAT. The mean age was 22.5 years (SD = 1.7) for youth and 40 years (SD = 10.2) for adults. Most youth (83%) and adults (87%) were treated with methadone. Compared to adults, youth were more likely to be female (OR = 1.67; 95% CI, 1.25-2.23) and less likely to have finished high school (OR = 0.53; 95% CI, 0.39-0.71). Youth were more likely to use drugs intravenously (OR = 1.47; 95% CI, 1.08-2.01) and to use cannabis (OR 1.78; 95% CI, 1.32-2.39); they were less likely to have started opioid use following a physician prescription (OR = 0.19; 95% CI, 0.13-0.29). Youth were enrolled in treatment for less time than adults (OR = 0.76; 95% CI, 0.71-0.82) but were more likely to be abstinent from opioids as measured by urine drug screen (UDS) before study entry (OR = 1.65; 95% CI, 1.22-2.22). Youth were more likely to meet the criteria for bipolar disorder (OR = 2.41; 95% CI, 1.20-4.83) and anxiety disorders (OR = 1.85; 95% CI, 1.08-3.17); they did not differ from adults for depression (OR = 1.15; 95% CI, 0.62-2.15), psychotic disorders (OR = 0.31; 95% CI, 0.04-2.44), or eating disorders (OR = 1.06; 95% CI, 0.12-9.45). Youth enrolled in OAT differ from adults on a number of dimensions: demographic characteristics, substance use, and mental illness comorbidity. These findings suggest areas of attention for clinical programs treating youth with OUD, including educational supports and management of co-occurring mental health disorders.

LONGITUDINAL ORAL ANTICOAGULANT ADHERENCE PATTERNS IN PATIENTS WITH ATRIAL FIBRILLATION: A RETROSPECTIVE OBSERVATIONAL STUDY

<h3>BACKGROUND</h3> Medication taking is a dynamic behavior that changes over time. Conventional adherence summary measures (e.g. proportion days covered) used in the OAC adherence studies conducted so far, however, are insensitive to the fluid nature of adherence. For example, identical PDC values can be calculated for patients with initial good adherence followed by poor adherence, and for those with periodic nonadherence throughout the course of therapy. The objective of this study was to characterise atrial fibrillation (AF) patients' long-term unique oral anticoagulant (OAC) adherence trajectories. <h3>METHODS AND RESULTS</h3> Using linked, population-based administrative data containing physician billings, hospitalization and prescription records of 4.8 million British Columbians (1996-2019), incident adult cases of AF were identified. Only patients who had prescription refill data available for five years were included in the analysis. The primary measure of OAC adherence was the proportion of days covered (PDC) over consecutive 90-day rolling windows. We modeled continuous 90-day PDC values over time. The time variable was number of years since OAC initiation. Group-Based Trajectory Modeling (GBTM) was used to identify patients' unique longitudinal adherence trajectories. To determine the best model, a relative comparison was done between models using Bayesian information criteria (BIC), and the Akaike information criterion (AIC). The study cohort was 19,749 AF patients [mean age 70.6y (SD 10.64), 56% male, mean CHA2DS2-VASc score 2.77 (SD 1.39]. The model that best fit our data identified four distinct OAC adherence trajectories. These were "consistent good adherence" (n=14,631 patients, 74.1% of the cohort), "rapid decline and discontinuation" (n=2327, 11.8%), "rapid decline with recovery"(n=1973, 9.99%), and "slow decline and discontinuation" (n=819, 4.2%). Our results show that there is heterogeneity among non-adherers. PDC dropped significantly in the first year after therapy initiation for those with "rapid decline and discontinuation" trajectory. Patients exhibiting "rapid decline with recovery" also displayed a rapid decline in adherence in the first year but showed improvements around the third year. Those in the "slow decline and discontinuation" trajectory displayed slow decline in adherence over first three years which eventually led to permanent discontinuation of therapy. <h3>CONCLUSION</h3> In this retrospective study we distinguished between the different kinds of non-adherence in terms of timing and rate. While a majority of our cohort adhered to their medications, we identified three unique trajectories displaying declining adherence over time at varying rates. Our results emphasize the importance of early intervention and have direct implications for improving the design of adherence interventions.

IMPACT OF ORAL ANTICOAGULANT CLASS ON ADHERENCE IN PATIENTS WITH ATRIAL FIBRILLATION: A 23-YEAR POPULATION-BASED COHORT STUDY IN CANADA

<h3>BACKGROUND</h3> Studies measuring OAC adherence in AF patients have suffered from short follow-up times, inability to account for frequent medication switches and have excluded warfarin. Our objective was to compare AF patients' long-term adherence between OACs and identify the impact of taking direct oral anticoagulants (DOAC) versus vitamin K antagonists (VKA) on adherence, while accounting for switching. <h3>METHODS AND RESULTS</h3> Using linked, population-based administrative data containing physician billings, hospitalization and prescription records of 4.8 million British Columbians (1996-2019), incident adult cases of AF were identified. Primary measure of adherence was proportion days covered (PDC). Consecutive rolling windows of 90 day in length were created for each patient starting from their first OAC prescription fill date until the end of their follow-up time. PDC for each of the 90-day-long rolling windows were calculated. If a person permanently discontinued their medication, they were given a PDC of 0 for all subsequent rolling windows after their last supply ran out, until the end of their follow-up period. As such, both poor execution and non-persistence were measured simultaneously. Patient's average adherence over follow-up was obtained by calculating the mean of PDC values of all their windows during follow-up. Changes in adherence over time and the association between drug class and adherence were assessed using generalized mixed effect linear regression model with both adherence and drug class treated as time-varying covariates. Study sample comprised of 30,264 AF patients [mean age: 72.2(SD11.0), 44.6% Female] with mean follow-up of 7.7(4.8) years. A majority were initiated on warfarin (69.7%), with mean CHA2DS2-VASc score of 2.94 (SD1.4). Mean PDC for our cohort was 0.71(SD0.27) with 51% considered non-adherent (PDC < 0.8). 40.20% of the cohort experienced OAC switches, most of them being between-class switches. Adherence dropped over time with the greatest decline in the first two years after therapy. After controlling for all other confounders, taking VKA compared to DOAC was, on average, associated with a 1-day decrease in number of days of medication taking per year. <h3>CONCLUSION</h3> Adherence to OACs in patients with AF was well below the conventional threshold of 80%, with less than half of the patients taking these medications as prescribed. Adherence dropped over time, particularly in the first two years after therapy initiation. Switching was common. Drug class had no meaningful impact on medication adherence.