Changes In Prescribing Research Articles

Drug-drug interactions in an intensive care unit and comparison of updates in two databases

ObjectiveCritically ill patients are at increased risk of drug-drug interactions but their prevalence and clinical relevance remains unclear. The prevalence of potential drug-drug interactions in an intensive care unit according to Micromedex Drug-Reax® and Lexi-Interact® databases was studied and the concordance between the two databases was assessed. In addition, drug-drug interactions detected in 2013 were compared with those identified in 2018 to determine updates between these years. MethodBetween January and June 2013, 152 critical care patients were prospectively included. Cardiac patients were excluded. Demographic and clinical data together with the drugs administered on the first calendar day of intensive care unit admission were recorded. Potential drug-drug interactions were searched in both Drug-Reax® and Lexi-Interact® and their prevalence, level of severity and evidence were compared considering the same sample in 2013 and 2018. ResultsIn 2013, 1,025 potential drug-drug interactions were identified, corresponding to 438 unique pairs. Lexi-Interact® identified more interactions (92.8%) than Drug-Reax® (34.0%). The percentage of agreement between databases was 274%. The number of interactions included in both databases increased after the five years but their level of evidence decreased. The most common potential drug-drug interactions involved sedatives and analgesics, intentionally prescribed concomitantly. Only two potential drug-drug interactions were classified as contraindicated by both databases. None of the potential drug-drug interactions identified had a noticeable clinical impact. Neither did they imply a prescription change. ConclusionsThis study shows that the prevalence of potential drug-drug interactions in the intensive care unit is high, although their clinical relevance is generally low. Our data also show a lack of concordance between Drug-Reax® and Lexi-Interact®, as well as their updates.

A pragmatic, open-label, randomized controlled trial of Plasma-Lyte-148 versus standard intravenous fluids in children receiving kidney transplants (PLUTO)

Acute electrolyte and acid-base imbalance is experienced by many children following kidney transplant. This is partly because doctors give very large volumes of artificial fluids to keep the new kidney working. When severe, fluid imbalance can lead to seizures, cerebral edema and death. In this pragmatic, open-label, randomized controlled trial, we randomly assigned (1:1) pediatric kidney transplant recipients to Plasma-Lyte-148 or standard of care perioperative intravenous fluids (predominantly 0.45% sodium chloride and 0.9% sodium chloride solutions). We then compared clinically significant electrolyte and acid-base abnormalities in the first 72 hours post-transplant. The primary outcome, acute hyponatremia, was experienced by 53% of 68 participants in the Plasma-Lyte-148 group and 58% of 69 participants in the standard fluids group (odds ratio 0·77 (0·34 - 1·75)). Five of 16 secondary outcomes differed with Plasma-Lyte-148: hypernatremia was significantly more frequent (odds ratio 3·5 (1·1 – 10·8)), significantly fewer changes to fluid prescriptions were made (rate ratio 0·52 (0·40-0·67)), and significantly fewer participants experienced hyperchloremia (odds ratio 0·17 (0·07 – 0·40)), acidosis (odds ratio 0·09 (0·04 - 0·22)) and hypomagnesemia (odds ratio 0·21 (0·08 – 0·50)). No other secondary outcomes differed between groups. Serious adverse events were reported in 9% of participants randomized to Plasma-Lyte-148 and 7% of participants randomized to standard fluids. Thus, perioperative Plasma-Lyte-148 did not change the proportion of children who experienced acute hyponatremia compared to standard fluids. However fewer fluid prescription changes were made with Plasma-Lyte-148, while hyperchloremia and acidosis were less common.

Compass for antibiotic stewardship: using a digital tool to improve guideline adherence and drive clinician behaviour for appendicitis treatment in the emergency department

BackgroundAntibiotic stewardship in the ED is important given the increasing prevalence of multidrug resistance associated with poorer patient outcomes. The use of broad-spectrum antibiotics in the ED for infections like...

Removal of Medicaid Prior Authorization Requirements and Buprenorphine Treatment for Opioid Use Disorder

Buprenorphine treatment for opioid use disorder (OUD) is associated with decreased morbidity and mortality. Despite its effectiveness, buprenorphine uptake has been limited relative to the burden of OUD. Prior authorization (PA) policies may present a barrier to treatment, though research is limited, particularly in Medicaid populations. To assess whether removal of Medicaid PAs for buprenorphine to treat OUD is associated with changes in buprenorphine prescriptions for Medicaid enrollees. This state-level, serial cross-sectional study used quarterly data from 2015 through the first quarter (January-March) of 2019 to compare buprenorphine prescriptions in states that did and did not remove Medicaid PAs. Analyses were conducted between June 10, 2021, and August 15, 2023. The study included 23 states with active Medicaid PAs for buprenorphine in 2015 that required similar PA policies in fee-for-service and managed care plans and had at least 2 quarters of pre- and postperiod buprenorphine prescribing data. Removal of Medicaid PA for at least 1 formulation of buprenorphine for OUD. The main outcome was number of quarterly buprenorphine prescriptions per 1000 Medicaid enrollees. Between 2015 and the first quarter of 2019, 6 states in the sample removed Medicaid PAs for at least 1 formulation of buprenorphine and had at least 2 quarters of pre- and postpolicy change data. Seventeen states maintained buprenorphine PAs throughout the study period. At baseline, relative to states that repealed PAs, states that maintained PAs had lower buprenorphine prescribing per 1000 Medicaid enrollees (median, 6.6 [IQR, 2.6-13.9] vs 24.1 [IQR, 8.7-27.5] prescriptions) and lower Medicaid managed care penetration (median, 38.5% [IQR, 0.0%-74.1%] vs 79.5% [IQR, 78.1%-83.5%] of enrollees) but similar opioid overdose rates and X-waivered buprenorphine clinicians per 100 000 population. In fully adjusted difference-in-differences models, removal of Medicaid PAs for buprenorphine was not associated with buprenorphine prescribing (1.4% decrease; 95% CI, -31.2% to 41.4%). For states with below-median baseline buprenorphine prescribing, PA removal was associated with increased buprenorphine prescriptions per 1000 Medicaid enrollees (40.1%; 95% CI, 0.6% to 95.1%), while states with above-median prescribing showed no change (-20.7%; 95% CI, -41.0% to 6.6%). In this serial cross-sectional study of Medicaid PA policies for buprenorphine for OUD, removal of PAs was not associated with overall changes in buprenorphine prescribing among Medicaid enrollees. Given the ongoing burden of opioid overdoses, continued multipronged efforts are needed to remove barriers to buprenorphine care and increase availability of this lifesaving treatment.

Quality control to improve LDL-cholesterol management in patients with acute coronary syndromes based on the ACS EuroPath IV project.

We performed quality control of lipid-lowering therapy (LLT) in patients with acute coronary syndrome (ACS), with a view to proposing corrective actions. Using a Define Measure Analysis Improve Control (DMAIC) approach applied to data from the ACS EuroPath IV survey, we measured attainment of two quality indicators (QIs) related to lipid-lowering treatment: (i) prescription of high-intensity statins (or equipotent treatment) before discharge, and (ii) proportion with LDL-cholesterol <55 mg/dL (1.4 mmol/L) during follow-up. A total of 530 European cardiologists responded and provided data for up to 5 patients from their centre, for acute and follow-up phases. Corrective measures are proposed to increase the rate of attainment of both QIs. Attainment of the first QI was measured in 929 acute-phase patients, 99% had LLT prescribed at discharge and 75% of patients fulfilled the first QI. Attainment of the second QI was assessed in 1721 patients with follow-up. The second QI was reached in 31% of patients. The DMAIC approach yielded 10 potential changes in prescription, 3 for the first and 7 for the second QI. The overall strategy is 'Fire to Target', i.e. early intensification of the LLT using statins, ezetimibe, bempedoic acid, and proprotein convertase subtilisin/kexin type-9 inhibitors, and is presented as an algorithm for routine application. Quality control for LLT, based on the ACS EuroPath IV survey, detected 10 potential changes in prescription that could enhance attainment of 2 QIs. Whether the Fire to Target strategy will be adopted and effective needs to be assessed in further steps of the EuroPath Quality programme.

Erectile Dysfunction Pharmacotherapy Utilization after 60Gy in 20 Fractions Volumetric Modulated Arc Therapy to the Prostate

To determine which factors predict for worsening erectile function after highly conformal, modestly hypofractionated radiotherapy to the prostate. All patients who received 60Gy in 20 fractions, volumetric modulated arc therapy to the prostate across 4 centers over 9 years were included in this study. The provincial electronic medical record was interrogated to identify any new prescriptions for erectile dysfunction (ED) medication, any change in prescription of ED medication or any permanent discontinuance of ED medication persisting beyond 6 months post completion of any androgen deprivation therapy. The penile bulb, penile crux and penile shaft structures were retrospectively contoured. A Youden receiver-operator-curve analysis, logistic regression, and neural network based interpretable machine learning analysis were then used to determine dependencies between worsening ED and clinical factors including mean doses to these structures. Two-hundred-twelve patients with median (inter-quartile-range) follow-up of 3.6 (3.2-4.4) years were identified. Median age was 72 (67-76) years. 104 (49%) patients received androgen deprivation therapy. Prior to treatment, 52 (25%) patients were on ED medication: 20 (9%) on sildenafil, 28 (13%) on tadalafil and 4 (8%) on vardenafil. Median PTV volume was 158.9 (129.8-192.1) cc. Median penile bulb, penile crux and penile shaft volumes were 4.7 (3.6-6.2) cc, 6.5 (5.1-8.5) cc and 93.3 (80.6-106.2) cc, respectively. PTV V95 was 99.8 (99.5-99.9)%. Mean doses to penile bulb, penile crux and penile shaft were 2094.8 (1306.2-3036.3) cGy, 2094.8 (1306.2-3036.3) cGy and 444.4 (313.2-650.5), respectively. Fifty-nine (28%) patients had a worsening of ED after treatment: 25 (12%) started a new ED medication, 6 (3%) had a prescription change and 28 (13%) stopped ED medication. On univariate analyses pretreatment use of ED medication predicted for worsening ED: odds ratio (OR) yes vs no: 10.2 (5.0 - 20.8; p<0.001). A trend towards mean dose to penile bulb [OR ≤2343.9 vs >2343.9: 1.7 (0.9-3.2; p = 0.08)] predicting for worsening ED was observed. Mean doses to penile crux [OR <1725.8 vs > 1725.8: 2.6 (1.3-5.2; p = 0.005)] and penile shaft [OR ≤344.9 vs >344.9: 5.2 (2.2-12.2; p<0.001)] predicted for worsening ED. Use of androgen deprivation therapy, and age at time of radiotherapy were not predictive of worsening ED. On multivariate analysis, only mean dose to penile shaft [OR ≤344.9 vs >344.9: 6.3 (1.9-20.3; p = 0.002)] and pretreatment use of ED medication [OR yes vs no: 11.1 (5.3-23.2; p<0.001)] predicted for worsening ED. A neural network analysis suggested that penile shaft mean dose and pre-treatment ED medication use are the most important factors in predicting worsening ED. In this limited analysis, pre-treatment use of ED medication and mean dose to penile shaft predicted for worsening ED after treatment with modestly hypofractionated radiotherapy for prostate cancer.

A system approach to improving guideline-directed therapy for cardio-renal-metabolic conditions: The “beyond diabetes” initiative

ObjectiveDespite demonstrating improvements in cardiovascular disease, kidney disease, and survival outcomes, guideline-directed antihyperglycemic medications such as sodium-glucose cotransporter 2 inhibitors (SGLT2i) and glucagon-like-peptide-1 receptor agonists (GLP1-RA), are underutilized. Many obstacles constrain their use including lack of systematic provider and patient education, concern for medication side effects, and patient affordability. MethodsWe designed a multimodality, systems-based approach to address these challenges with the goal of increasing medication utilization across the largest healthcare system in New York State. This multispecialty collaborative included provider and patient education, an electronic health record-enabled platform to identify eligible patients, and access to pharmacists for medication guidance and addressing insurance coverage barriers. Surveys were administered following grand rounds lectures and knowledge-based questionnaires were given before and after case-based sessions for housestaff, with results analyzed using a two-sided Student's t-test. Rates of first prescriptions of SGLT2i/GLP1-RA in combined and individual analyses were compared between the pre- and post-education periods (6 months prior to 3/31/2021 and 6 months post 8/19/2021), and the change in prescriptions per 100 eligible-visits was assessed using the incidence density approach. ResultsAmong grand rounds participants, 69.3% of respondents said they would make changes to their clinical practice. Knowledge increased by 14.7% (p-value <0.001) among housestaff following case-based sessions. An increase in SGLT2i/GLP1-RA prescribing was noted for eligible patients among internal medicine, cardiology, nephrology, and endocrinology providers, from 11.9 per 100 eligible visits in the pre-education period to 14.8 in the post-education period (absolute increase 2.9 [24.4%], incidence risk ratio 1.24 [95% CI 1.18–1.31]; p-value <0.001). Increases in prescribing rates were also seen among individual medical specialties. ConclusionsOur “Beyond Diabetes” initiative showed an improvement in provider knowledge-base and was associated with a modest, but statistically significant increase in the use of SGLT2i and GLP1-RA throughout our healthcare system.

50 Employing Shared Decision Making (SDM) to reduce NSAID-related harm and hospitalisations, in at-risk patients in primary care

Abstract Background 10% of hospital admissions in Ireland are Adverse Drg Reaction (ADR) related, and 71% of these are potentially avoidable. NSAID-related ADRs have been implicated in up to 30% of all ADR-related admissions. Addressing NSAID related STOPP criteria may prevent hospital admissions with bleeding, Cerebrovascular (CV) events and renal impairment. If stopping NSAID is not possible, dose reductions or drug switches can minimise the risk of harm. Preferred NSAIDs are naproxen (lower CV risk) or ibuprofen &amp;lt;1,200 mg/day (lower CV and gastrointestinal bleed risk). Methods Patients aged ≥65 years with valid prescriptions for NSAIDs were identified via software search using the M01 ATC classification system code. Each patients file was reviewed for NSAID related STOPP criteria. Specific software searches using additional ATC classification system codes were undertaken to identify those at high risk of harm e.g. NSAID with anticoagulant. Patients were engaged in Shared Decision Making (SDM) with the practice pharmacist and prescription changes were agreed and enacted by the GP. Results 63 patients&amp;gt;65 yrs had a valid prescription for an NSAID. 42 had ≥1 NSAID related STOPP criteria. 35 were deemed appropriate for intervention. 7 were prescribed a preferred NSAID and had mild hypertension only. 23 were deemed at high risk of harm. Software searches identified the same 23 high risk patients. 35 patients were engaged in SDM. 100% of these agreed to a change to their prescription. 51% stopped their NSAID whilst 40% changed or dose reduced their NSAID and 9% agreed to addition of gastroprotection. This achieved an overall 60% STOPP resolution rate. A higher average 91% resolution rate was achieved in the higher-risk patients. Conclusion SDM achieves higher STOPP resolution rates in patients at higher risk of harm who are identifiable though specific GP practice software searches. These software searches can be employed annually to effectively and efficiently prioritise patients for SDM interventions.

324 Statin prescribing in ischaemic stroke patients: quality improvement of an acute stroke ward in a model 4 tertiary teaching hospital

Abstract Background Stroke remains the leading cause of long-term disability. High cholesterol is associated with increased risk of stroke. Treatment with high intensity statins, as recommended by the SPARCL trial, is effective in reducing recurrence risk. The Medicines Management Programme recommends atorvastatin as the preferred drug, which can be given at any time of the day. With the majority of medications administered in the morning, clustering of medications is associated with higher adherence rates. Low statin adherence is associated with greater risk of death. Methods A point prevalence audit was carried out in an dedicated stroke ward in a tertiary model 4 teaching hospital. The data collected included sex, age, number of days since admission, pre-admission statin administration, current statin prescribed, dose, time of administration and change in current vs pre-admission prescription. Results were collected, analysed and compared with the above evidence. Results 21 inpatients with ischaemic stroke were included. Age ranged from 36 to 89 years, with a mean age of 73. 52% were female. Number of days since admission ranged from 1 to 165, with an average of 48. 13 patients were taking a statin prior to presentation, and 19 at time of data collection. Prescribed statins included atorvastatin and rosuvastatin. 76% had a change in statin type or dose during admission. 95% of patients were prescribed their statin at night time. Conclusion Appropriate statin prescribing is an essential part of secondary prevention. Long acting statin should be prescribed at a time that optimises compliance. We hypothesise that long acting statins including atorvastatin/rosuvastatin when given in the morning with other medications will increase compliancy. In line with the PDSA cycle, a planned education session, in conjunction with the pharmacy department, will take place focusing on atorvastatin/rosuvastatin prescribing, with re-audit following this, to ensure sustained change in practice.

Association of Long-acting Injectable Antipsychotics with Inpatient Seclusion and Restraint Events at a Public Psychiatric Hospital

Objective: Seclusion and restraint (S/R) are emergency safety measures to manage aggressive behaviour and prevent physical harm to self and others during psychiatric hospitalisations. Antipsychotics have been reported to reduce the incidence of S/R events during psychiatric hospitalisation. This study explores factors associated with inpatient S/R events and investigates whether long-acting injectable (LAI) antipsychotic prescription is associated with a reduction of S/R events. Method: Data on the number of S/R events during hospital stay were collected from the medical records of 741 psychiatric inpatients admitted between 2012 and 2017, and categorised into groups of 0, 1–2 and recurrent (≥3) S/R. Multinomial logistic regression analysis was performed to find the association between S/R events and several demographic and clinical variables, including the time to initiation of LAI (TLAI). Results: TLAI was not significantly associated with S/R events. Antipsychotic medication prescription was associated with a decreased risk of recurrent S/R events (OR = 0.47; 95% Cl = 0.24–0.92), however, it was not significant for the group having 1–2 S/R events (OR = 0.74; 95% Cl = 0.37–1.49). Individuals with recurrent S/R events were more likely to have forensic admission, transfer from jail or supervised facility, higher psychiatric comorbidity, and higher inpatient medications and prescription changes. Conclusion: Early initiation of LAI antipsychotics was not associated with S/R events; however, routine oral antipsychotic medication prescription was associated with decreased risk of S/R events. Specific predictors of S/R episodes may be used in preventative efforts aimed at decreasing S/R events.

'Auspicious liaisons'-evaluating the impact of a liaison geriatrician initiative on older adults psychiatric wards.

Although liaison services in acute hospitals are now the norm, the reverse is not usually available for patients in mental health trusts. Following the introduction of support from geriatricians to older people's mental health inpatient wards, we wanted to see if this intervention was effective and acceptable to clinicians. We performed a retrospective cohort service evaluation on the impact of a liaison geriatrician, using routinely collected data, and assessed acceptability among medical staff by semi-structured interview. Our service introduced regular sessions from consultant community geriatricians across older adults psychiatric wards including a mixture of video conference and face-to-face input. There was no significant decrease in emergency transfers but there was a significant reduction in length of stay with an associated cost benefit for the service after the introduction of a liaison geriatrician. There was a significant increase in geriatrician consultations and a decrease in specialty consultations to other specialists. There was no change in discharge prescriptions or destination. There was a significant reduction in falls in the intervention arm but not in falls leading to emergency hospital admissions geriatricians gave confidence to psychiatrists of all grades to treat physical health care issues. A liaison geriatrician service may be a component in reducing length of stay (although there are many others) and improving continuity of care, although it confers no impact on emergency transfers. The intervention was highly acceptable to clinicians.

Reducing opioid prescribing after ambulatory breast reconstruction surgery.

The lack of evidence-based guidelines for postoperative opioid prescriptions following breast reconstruction contributes to a wide variation in prescribing practices and increases potential for misuse and abuse. Between August and December 2019, women who underwent outpatient breast reconstruction were surveyed 7-10 days before (n = 97) and after (n = 101) implementing a standardized opioid prescription reduction initiative. We compared postoperative opioid use, pain control, and refills in both groups. Patient reported outcomes were compared using the BREAST-Q physical wellbeing of the chest domain and a novel symptom Recovery Tracker. Before changes in prescriptions, patients were prescribed a median of 30 pills and consumed three pills (interquartile range [IQR: 1,9]). After standardization, patients were prescribed eight pills and consumed three pills (IQR: 1,6). There was no evidence of a difference in the proportion of patients experiencing moderate to very severe pain on the Recovery Tracker or in the early BREAST-Q physical wellbeing of the chest scores (p = 0.8 and 0.3, respectively). Standardizing and reducing opioid prescriptions for patients undergoing reconstructive breast surgery is feasible and can significantly decrease the number of excess pills prescribed. The was no adverse impact on early physical wellbeing, although larger studies are needed to obtain further data.

Pronounced State-Level Disparities in Medicaid Prescribing of Buprenorphine for Opioid Use Disorder (2019-2020).

The purpose of this study was to analyze buprenorphine prescribing across states in Medicaid patients during 2019-2020. Buprenorphine prescriptions per Medicaid enrollee per state were calculated for 2019 and 2020. Data analysis was conducted with buprenorphine formulations that are approved by the U.S. Food & Drug Administration for opioid use disorder (OUD; including generic and brand name formulations of buprenorphine mono product and buprenorphine/naloxone combination products) using Microsoft Excel. The totals of mono product buprenorphine were divided over the total of combination buprenorphine/naloxone in 2019 and 2020 to obtain the ratio of mono/combo. Formulations of buprenorphine indicated for pain were excluded. States outside 95% confidence intervals (1.96 standard deviations above and below the mean) were considered statistically significant. The overall change in buprenorphine prescribing between 2019 and 2020 was modest (+3.6%) but highly variable, with more than a 10% increase in 17 states (Iowa = +100.5%, p < .05) but more than a 10% decrease in 9 states (Alabama = -68.5%, p < .05). Total amount reimbursed in 2019 increased (+9.9%) to $1.42 billion in 2020. Branded formulations accounted for two fifths (39.5%) of prescribing but more than two thirds (66.8%) of spending in 2020. The COVID-19 pandemic exacerbated state-level disparities in buprenorphine prescribing for OUD among Medicaid patients. Legislation expanding buprenorphine-waivered providers and Medicaid expansion may have contributed to the statistically significant changes in state buprenorphine prescriptions.

Changes in Antithrombotic Therapy Prescription in Patients with a Combination of Atrial Fibrillation and Myocardial Infarction in a Specialised Inpatient Department from 2016-2019 and Associations with Prognosis.

Background and Objectives: The problem of treating patients with atrial fibrillation and myocardial infarction is relevant. The issue of optimal antithrombotic therapy in these patients has not been definitively resolved. This work analyzes the influence of clinical factors and treatment on the long-term prognosis of patients. Materials and Methods: The research included 360 patients with atrial fibrillation and myocardial infarction during 2016-2019. Results: The factors associated with fatal outcomes were age (hazard ratio (HR): 1.05; 95% confidence interval (CI): 1.03-1.07; p < 0.001); stroke (HR: 1.95; 95% CI: 1.27-3.00; p = 0.0002); glomerular filtration rate (HR: 0.988; 95% CI: 0.978-0.998; p = 0.03); left ventricular ejection fraction (HR: 0.975; 95% CI: 0.957-0.999; p = 0.007); and aspirin (HR: 0.48; 95% CI: 0.31-0.73; p < 0.001). The factors associated with the combined endpoint were chronic kidney disease (HR: 1.46; 95% CI: 1.01-2.10; p = 0.04); HAS-BLED (HR: 1.23; 95% CI: 1.06-1.43; p = 0.007); percutaneous coronary intervention (HR: 0.70; 95% CI: 0.51-0.96; p = 0.03); and aspirin (HR: 0.65; 95% CI: 0.44-0.97; p = 0.03). Conclusions: Double and triple antithrombotic therapy were not associated with outcomes. Aspirin improved the prognosis for survival and the combined endpoint.

The association between patients' frailty status, multimorbidity, and demographic characteristics and changes in primary care for chronic conditions during the COVID-19 pandemic: a pre-post study.

The purpose of this study was to assess the impact of SARS-COV-2 (Severe acute respiratory syndrome coronavirus 2) pandemic on primary care management (frequency of monitoring activities, regular prescriptions, and test results) of older adults with common chronic conditions (diabetes, hypertension, and chronic kidney disease) and to examine whether any changes were associated with age, sex, neighbourhood income, multimorbidity, and frailty. A research database from a sub-set of McMaster University Sentinel and Information Collaboration family practices was used to identify patients ≥65 years of age with a frailty assessment and 1 or more of the conditions. Patient demographics, chronic conditions, and chronic disease management information were retrieved. Changes from 14 months pre to 14 months since the pandemic were described and associations between patient characteristics and changes in monitoring, prescriptions, and test results were analysed using regression models. The mean age of the 658 patients was 75 years. While the frequency of monitoring activities and prescriptions related to chronic conditions decreased overall, there were no clear trends across sub-groups of age, sex, frailty level, neighbourhood income, or number of conditions. The mean values of disease monitoring parameters (e.g. blood pressure) did not considerably change. The only significant regression model demonstrated that when controlling for all other variables, patients with 2 chronic conditions and those with 4 or more conditions were twice as likely to have reduced numbers of eGFR (Estimated glomerular filtration rate) measures compared to those with only 1 condition ((OR (odds ratio) = 2.40, 95% CI [1.19, 4.87]); (OR = 2.19, 95% CI [1.12, 4.25]), respectively). In the first 14 months of the pandemic, the frequency of common elements of chronic condition care did not notably change overall or among higher-risk patients.

Changes in Polypharmacy and Potentially Inappropriate Medications in Homebound Older Adults in Japan, 2015-2019: a Nationwide Study.

With rising worldwide population aging, the number of homebound individuals with multimorbidity is increasing. Improvement in the quality of home medical care (HMC), including medications, contributes to meeting older adults' preference for "aging in place" and securing healthcare resources. To evaluate the changes in drug prescriptions, particularly potentially inappropriate medications (PIMs), among older adults receiving HMC in recent years, during which measures addressing inappropriate polypharmacy were implemented, including the introduction of clinical practice guidelines and medical fees for deprescribing. A cross-sectional study. Using data from the national claims database in Japan, this study included older adults aged ≥ 75years who received HMC in October 2015 (N = 499,850) and October 2019 (N = 657,051). Number of drugs, prevalence of polypharmacy (≥ 5 regular drugs), major drug categories/classes, and PIMs according to Japanese guidelines were analyzed. Random effects logistic regression models were used to evaluate the differences in medications between 2015 and 2019, considering the correlation within individuals who contributed to the analysis in both years. The number of drugs remained unchanged from 2015 to 2019 (median: 6; interquartile range: 4, 9). The prevalence of polypharmacy also remained unchanged at 70.0% in both years (P = 0.93). However, the prescription of some drugs (e.g., direct oral anticoagulants, new types of hypnotics, acetaminophen, proton pump inhibitors, and β-blockers) increased, whereas others (e.g., warfarin, vasodilators, H2 blockers, acetylcholinesterase inhibitors, and benzodiazepines) decreased. Among the frequently prescribed PIMs, benzodiazepines/Z-drugs (25.6% in 2015 to 21.1% in 2019; adjusted odds ratio: 0.52) and H2 blockers (11.2 to 7.3%; 0.45) decreased, whereas diuretics (23.8 to 23.6%; 0.90) and antipsychotics (9.7 to 10.5%; 1.11) remained unchanged. We observed some favorable changes but identified some continuous and new challenges. This study suggests that continued attention to medication optimization is required to achieve safe and effective HMC.

Tracking changes in opioid prescriptions dispensed following the enactment of a prescription drug monitoring program use mandate

BackgroundPrescription drug monitoring programs (PDMPs) are state-based surveillance tools used to track controlled substances dispensed to patients and identify patients at-risk of misuse. Starting April 2017, Wisconsin required all prescribers access PDMP to review patient information before issuing a controlled substance prescription order for more than a 3-day supply. A primary goal of PDMP use mandates is to reduce avoidable prescribing and mitigate opioid related mortality and morbidity. Current literature has not evaluated the existence of a time point post-policy implementation, at which the trend in opioid dispensing changes, reflecting normalization/maintenance of opioid prescribing. ObjectiveWe sought to evaluate the impact of the PDMP use mandate on trends in opioid prescriptions dispensed and test a hypothesis that a change or inflection in opioid prescriptions dispensed occurred post-mandate implementation. MethodsInterrupted Time Series Analysis (ITSA) design was used to examine whether the level (immediate impact) and trend in opioid prescribing changed significantly after the PDMP use mandate was implemented. We used a novel Change Point Analysis (CPA) approach to test the hypothesis i.e., identify if and when a change or inflection in opioid dispensing trend occurred after implementation of the PDMP use mandate. ResultsITSA model results showed a significant drop in opioid prescriptions dispensed (p < 0.05) immediately after the mandate implementation (i.e., April 2017). Results of the CPA identified a significant inflection in opioid prescriptions dispensed starting January 2019 (21-months post-policy implementation). An ITSA model using the inflection point as an interruption showed that the trend in opioid prescriptions dispensed became flatter after the inflection point, suggesting normalization. ConclusionUsing a novel CPA approach, the findings showed an inflection in the trend in opioid prescriptions dispensed post-PDMP use mandate implementation, implying that most of the avoidable prescribing likely was curtailed. The results suggest that the patient information presumably accessed from the WI PDMP interface was useful in helping prescribers to make an informed clinical decision about opioid prescribing.

Increase in the community circulation of ciprofloxacin-resistant Escherichia coli despite reduction in antibiotic prescriptions

BackgroundCommunity circulating gut microbiota is the main reservoir for uropathogenic Escherichia coli, including those resistant to antibiotics. Ciprofloxacin had been the primary antibiotic prescribed for urinary tract infections, but its broad use has been discouraged and steadily declined since 2015. How this change in prescriptions affected the community circulation of ciprofloxacin-resistant E. coli is unknown.MethodsWe determined the frequency of isolation and other characteristics of E. coli resistant to ciprofloxacin in 515 and 1604 E. coli-positive fecal samples collected in 2015 and 2021, respectively. The samples were obtained from non-antibiotic-taking women of age 50+ receiving care in the Kaiser Permanente Washington healthcare system.ResultsHere we show that despite a nearly three-fold drop in the prescription of ciprofloxacin between 2015 and 2021, the rates of gut carriage of ciprofloxacin-resistant E. coli increased from 14.2 % to 19.8% (P = .004). This is driven by a significant increase of isolates from the pandemic multi-drug resistant clonal group ST1193 (1.7% to 4.2%; P = .009) and isolates with relatively few ciprofloxacin-resistance determining chromosomal mutations (2.3% to 7.4%; P = .00003). Though prevalence of isolates with the plasmid-associated ciprofloxacin resistance dropped (59.0% to 30.9%; P = 2.7E-06), the isolates co-resistance to third generation cephalosporins has increased from 14.1% to 31.5% (P = .002).ConclusionsDespite reduction in ciprofloxacin prescriptions, community circulation of the resistant uropathogenic E. coli increased with a rise of co-resistance to third generation cephalosporins. Thus, to reduce the rates of urinary tract infections refractory to antibiotic treatment, greater focus should be on controlling the resistant bacteria in gut microbiota.

Participation in the Georgia Food for Health programme and CVD risk factors: a longitudinal observational study.

To assess the relationship between programme attendance in a produce prescription (PRx) programme and changes in cardiovascular risk factors. The Georgia Food for Health (GF4H) programme provided six monthly nutrition education sessions, six weekly cooking classes and weekly produce vouchers. Participants became programme graduates attending at least 4 of the 6 of both the weekly cooking classes and monthly education sessions. We used a longitudinal, single-arm approach to estimate the association between the number of monthly programme visits attended and changes in health indicators. GF4H was implemented in partnership with a large safety-net health system in Atlanta, GA. Three hundred thirty-one participants living with or at-risk of chronic disease and food insecurity were recruited from primary care clinics. Over three years, 282 participants graduated from the programme. After adjusting for programme site, year, participant sex, age, race and ethnicity, Supplemental Nutrition Assistance Program participation and household size, we estimated that each additional programme visit attended beyond four visits was associated with a 0·06 kg/m2 reduction in BMI (95 % CI -0·12, -0·01; P = 0·02), a 0·37 inch reduction in waist circumference (95 % CI -0·48, -0·27; P < 0·001), a 1·01 mmHg reduction in systolic blood pressure (95 % CI -1·45, -0·57; P < 0·001) and a 0·43 mmHg reduction in diastolic blood pressure (95 % CI -0·69, -0·17; P = 0·001). Each additional cooking and nutrition education visit attended beyond the graduation threshold was associated with modest but significant improvements in CVD risk factors, suggesting that increased engagement in educational components of a PRx programme improves health outcomes.

To study the effects of online teaching on eyes of school going children during COVID pandemic

During COVID pandemic, with schools being closed, digital platforms are being extensively used for online teaching and learning. Children are being exposed to video display units (VDU) for prolonged durations making them susceptible to ocular problems and development of the Computer Vision Syndrome. Through this study, we attempted to study the effect of this added use of VDUs through online teaching on eyes of school going children. A Google survey of 18 questions was prepared assessing the pattern of online teaching sessions, type of devices used, use of protective accessories and presence of ocular symptoms. The form was floated on social platforms for parents of school going children. Data was collected and analysed using Microsoft Excel and percentage and p value calculated using chi square test. Out of 982 children, 494 (50.3%) had one or more ocular symptoms. Headache was found in 205(41.49%), excessive rubbing of eyes in 178 (36.03%), pain in 155 (31.37%), redness in 135 (27.32%), watering in 132 (26.72%), blurring of vision in 67 (13.56%) and changes in glass prescription in 42 (8.50%) children. We found total duration of online class and continuous use of VDUs to be statistically significant influencing factors. Online teaching learning should be cautiously conducted as the use of VDUs can affect the ocular health of the children.