Prescription Status Research Articles

Factors associated with oral anticoagulant prescription status among patients with a new diagnosis of atrial fibrillation.

Atrial fibrillation (AF) is the most common sustained arrhythmia in adults and increases stroke risk. Treatment with oral anticoagulants (OACs) may reduce this risk however many patients do not receive OAC therapy. This study aimed to use electronic health record data to identify newly diagnosed AF patients at high risk for stroke and not anticoagulated as well as factors associated with OAC prescription. Timely prescription of OACs among patients with newly diagnosed AF is poor. We performed a retrospective study of patients with a new diagnosis of AF. We assessed stroke risk with the CHA2 DS2 -VASc score. The primary outcome was prescription of an OAC within 6 months following diagnosis. We used logistic regression to see how the odds of being prescribed an OAC differs for 17 independent variables. We identified 18 404 patients with a new diagnosis of AF. Among patients at high risk for stroke, 41.3% received an OAC prescription within 6 months. Male sex, Caucasian compared to African American race, stroke, obesity, congestive heart failure, vascular disorder, current antiplatelet, beta blocker, or calcium channel blocker prescription, and increasing CHA2 DS2 -VASc score were positively associated with receiving an OAC. Whereas anemia, renal dysfunction, liver dysfunction, antiarrhythmic drug use and increasing HAS-BLED score were negatively associated. Most newly diagnosed AF patients at high stroke risk do not receive an OAC prescription in the first 6 months following diagnosis. Our analysis suggests that patient sex, race, comorbidities, and additional prescriptions are associated with rates of OAC prescribing.

Relationship between antidementia medication and fracture prevention in patients with Alzheimer’s dementia using a nationwide health insurance claims database

This retrospective study aimed to evaluate the association between antidementia medication use and incidence of new vertebral, hip, and radial fractures in patients with Alzheimer’s dementia (AD). We used the nationwide health insurance claims database of Japan from 2012 to 2019 and identified 12,167,938 patients aged ≥ 65 years who were newly registered from April 2012 to March 2016 and had verifiable data receipt from half-year before to 3 years after the registration. Among these patients, 304,658 were diagnosed with AD and we showed the prescription status of antidementia and osteoporosis medication among them. Propensity score matching was conducted for AD group with and without antidementia medication use, and 122,399 matched pairs were yielded. The incidence of hip fractures (4.0% vs. 1.9%, p < 0.001) and all clinical fractures (10.5% vs. 9.0%, p < 0.001) significantly decreased and that of radial fractures increased (0.6% vs. 1.0%, p < 0.001) in AD patients with antidementia medication use compared with AD patients without antidementia medication use. No significant difference was found in vertebral fractures (6.6% vs. 6.5%, p = 0.51). Overall, these results suggest a positive relationship between antidementia medication use and fracture prevention in patients with AD.

Durable Viral Suppression Among Young Adults Living with HIV Receiving Ryan White Services in New York City.

Identifying factors associated with durable viral suppression (DVS) can inform interventions to support young adults living with HIV (YALWH) in sustaining optimal health. We examined associations between client characteristics and DVS among YALWH aged 18-29 who completed an intake assessment and received ≥ 1 Ryan White Part A service in New York City from 1/2017 to 12/2019. Individuals were classified as achieving DVS at least once if they had ≥ 2 suppressed viral load test results ≥ 90 days apart with: (a) no intervening unsuppressed viral load test results in a 12-month period; and (b) no unsuppressed viral load test results after achieving DVS in that 12-month period. Of 2208 YALWH, 92.1% (n = 2034) had sufficient data in the New York City HIV Surveillance Registry to ascertain DVS status. Of these, 68% achieved DVS at least once. Controlling for ART prescription status at intake, YALWH with higher incomes were significantly more likely to achieve DVS at least once. YALWH with lifetime and recent histories of incarceration and/or drug use were significantly less likely to achieve DVS. Our findings underscore the potential role of tailored harm reduction and post-incarceration programs in reducing health inequities among YALWH.

Satisfaction with opioid prescription and use after minor gynaecologic surgery: a pilot prospective study

To describe predictors of patient satisfaction with pain control including opioid prescribing practices, patients undergoing minor gynaecologic and urogynaecologic surgeries were included in a prospective cohort study. Satisfaction with postoperative pain control by opioid prescription status was analysed using bivariate analysis and multivariable logistic regression, controlling for potential confounders. Among participants completing both postoperative surveys, 112/141 (79.4%) reported pain control satisfaction by day 1–2 and 118/137 (86.1%) by day 14. While we were underpowered to detect a true difference in satisfaction by opioid prescription, there were no differences in opioid prescription among patients satisfied with pain control [52% vs. 60% (p = .43) among satisfied patients at day 1–2 and 58.5% vs. 37% (p = .08) at day 14]. Significant predictors of pain control satisfaction were postoperative day (POD) 1–2 average pain at rest [aOR 0.72 (95% CI 0.52–0.99), p = .04], rating of shared decision-making [aOR 1.16 (95% CI 1.004–1.34), p = .04], amount of pain relief [aOR 1.28 (95% CI 1.07–1.54), p = .008) and POD 14 shared decision-making rating [aOR 1.45 (95% CI 1.19–1.77), p = .002]. Impact Statement What is already known on this subject? There are little data published on opioid prescription rates after minor gynaecologic procedures and no formal evidence-based guidance for gynaecologic providers for opioid prescribing. Few publications describe rates of opioid prescription and use following minor gynaecologic procedures. In the setting of a dramatic escalation of opioid misuse in the United States over the last decade, we sought to describe our practice of opioid prescription following minor gynaecologic procedures and answer the question of whether patient satisfaction is affected by opioid prescription, fill and use. What do the results of this study add? Though underpowered to detect our primary outcome, our results suggest that patient satisfaction with pain control may primarily be significantly affected by the patient’s subjective assessment of shared decision-making with the gynaecologist. What are the implications of these findings for clinical practice and/or further research? Ultimately, these preliminary findings suggest a larger cohort is needed to answer the question of whether pain control satisfaction is influenced by receipt/fill/use of opioids after minor gynaecologic surgery.

Patient Acceptance of Prescribed and Fully Reimbursed mHealth Apps in Germany: An UTAUT2-based Online Survey Study

The study aims to (1) investigate current levels of patient acceptance of mHealth in Germany; (2) determine the influencing factors of patients' intention to use, and (3) test the influence of prescription and reimbursement status on patient acceptance. Online survey with 1349 participants, of which 1051 were complete and included for statistical analysis, from a broad cross-section of the German population, addressing both users of mobile health (mHealth) applications and people without prior experience. SEM modeling based on a combination of two theoretical frameworks: the extended Unified Theory of Acceptance and Use of Technology and Health Protective Behavior Theories were used to assess acceptance. Users of mHealth in Germany are mostly patients between the ages of 30 – 50 with mental health or endocrine conditions. General willingness to use mHealth apps / DiGAs (mHealth apps fully reimbursed by social health insurance) is high at 76%, especially if they are governmentally certified, however only 27% of respondents were willing to pay out of pocket. With the exception of a spike in performance expectancy and data security, DiGAs lack a clear differentiation from mHealth apps. Perceived self-efficacy and performance expectancy are significant predictors of willingness to use digital health interventions; with age, attitude, and e-literacy being key demographic predictors. A key takeaway for regulators, providers of mHealth apps/ DiGAs, and other stakeholders involved in mHealth adoption is the importance of addressing negative beliefs early on, targeted communication around effortless usage of mHealth services across age groups and demographics, and focus on highlighting expected benefits of mHealth app/ DiGA usage.

Analysis of prescription status of antihypertensive drugs in Chinese patients with hypertension based on real-world study

Background Globally, the prevalence of hypertension and the accompanying burden of cardiovascular disease are increasing. Through drug utilization research, we can understand the prescription status of hypertension patients and promote rational drug use. The purpose of this retrospective study was to describe the current prescription pattern of antihypertensive drugs in Chinese patients and determine the compliance level of treatment guidelines. Materials and methods Around 11.1 million patients who received a prescription for antihypertensive therapy between January 2021 to December 2021 were obtained from a database of Hangzhou Kang Sheng Health Consulting CO., Ltd. Results The mean age of hypertensive patients was 54.75 ± 12.98 years. About 6.7 million (60.30%) were males. About 46.07% of patients had comorbidities. The most common classes of antihypertensive medications used were calcium channel blockers (CCBs) and angiotensin II receptor blockers (ARBs). Around 78.33% of participants were on monotherapy. Diuretics + ARBs and Diuretics + CCBs + ARBs were the most commonly prescribed pattern in two-drug combination therapy and three-drug combination therapy, respectively. Conclusions CCBs and ARBs were the two most frequently prescribed for patients with hypertension. The prescription pattern of antihypertensive medications in the study largely complied with recommended Chinese hypertension guidelines. Key messages Cardiovascular disease is the most common complication of hypertension. Calcium channel blockers (CCBs) and angiotensin II receptor blockers (ARBs) are the two most commonly used drugs for hypertension patients in China. The proportion of combination prescription pattern in Chinese hypertensive patients is low.

Investigation of Prescription Status and Exploration of Risk Factors Related to Denosumab-Induced Hypocalcemia in Combination Therapy with 1α,25-Dihydroxy-vitamin D3.

To prevent denosumab-induced hypocalcemia in patients with renal dysfunction, combination therapy with 1α,25-dihydroxy-vitamin D3 (active vitamin D) is recommended. We previously developed a risk prediction model for hypocalcemia in patients with cholecalciferol/calcium (natural vitamin D). However, the prescription status and the risk factors of patients with active vitamin D have not been identified, so we designed this retrospective observational study using a large practice database covering June 2013 to May 2020 to analyze prescription status and risk factors. Patients were classified according to vitamin D type. After that, factors associated with development of hypocalcemia in patients with active vitamin D were explored. Univariate analysis was conducted to compare patient backgrounds between the hypocalcemia and non-hypocalcemia groups. Receiver operating characteristic analysis was conducted to evaluate the predictive potential of the extracted factors. Of the 33442 patients who received denosumab, 22347 and 3560 patients were co-administered natural and active vitamin D, respectively. Patients with active vitamin D had significantly lower renal function (estimated glomerular filtration rate (eGFR) median: 74.0 vs. 69.7 mL/min/1.73 m2), but some patients (23.6%) with sufficient renal function (eGFR ≥90) were also receiving active vitamin D. Of the 3560 patients with active vitamin D, non-hypocalcemia (n = 166) and hypocalcemia (n = 17) groups who met the study criteria were analyzed. Renal function was lower in the hypocalcemia group, and alkaline phosphatase gave the best discrimination. High aspartate aminotransferase (AST), renal dysfunction, high alkaline phosphatase (ALP), and low hemoglobin may be significant factors in risk prediction for hypocalcemia in patients with active vitamin D.

Current Prescription Status of Contraindicated Drug Combinations Causing Serotonin Syndrome: Analysis of HIRA-NPS Data

Current Prescription Status of Contraindicated Drug Combinations Causing Serotonin Syndrome: Analysis of HIRA-NPS Data

2088. Real-World Geographic Variations of HIV Diagnosis Rates among Individuals Prescribed and not Prescribed Oral HIV Pre-Exposure Prophylaxis (PrEP) Regimens in the United States

Abstract Background Declines in the diagnoses of new HIV infections have been reported in geographic areas with higher uptake of PrEP among persons who would benefit from PrEP (PWBP). In the present analysis, we examined the rate of new HIV diagnoses in PWBP prescribed PrEP and those not prescribed PrEP in order to understand the current and potential impact of PrEP in differing geographies. Methods We estimated the rate of new HIV infections among PWBP not prescribed PrEP with a previously described model (Mera et al. 2019) using a combination of published reports and a claims database. HIV rates for individuals prescribed F/TAF or F/TDF (including brand and generic) for PrEP between 10/3/2019 (F/TAF approval) and 6/30/2021 were analyzed from claims data. For those prescribed PrEP, new infections included new HIV diagnosis or addition of HIV treatment within 10 days of PrEP discontinuation. Results Overall, the US HIV diagnosis rate was 61% lower among PWBP prescribed PrEP (1.33 per 100-person year [95%CI: 1.24 – 1.42]) compared to those not prescribed PrEP (3.38 [3.35 – 3.42]). New HIV diagnosis rates by state among PWBP not prescribed PrEP ranged from 0.41 (0.22 – 0.78) in Vermont to 9.96 (9.53 – 11.54) in Mississippi (Figure). The Southern US had the highest regional HIV diagnosis rate among PWBP not prescribed PrEP (4.20 [4.14 - 4.26], Table). HIV diagnosis rates by state among PWBP prescribed PrEP were lower, ranging from 0 to 2.40 (0.05 – 4.75). Eleven states had a greater than 85% lower HIV diagnosis rate among PWBP prescribed PrEP versus those who were not prescribed PrEP, and the greatest differences in diagnosis rates by PrEP prescription status were observed in the Southeastern US states. Figure:The estimated rates of new HIV diagnosis (per 100 person-years) among PWBP who were not prescribed PrEP in 2019 (A) and those prescribed PrEP from 10/3/2019 to 6/30/2021 (B) in the United States.Table:Regional variations of new HIV diagnosis rates among PWBP who were not prescribed PrEP in 2019 and those prescribed PrEP from 10/3/2019 to 6/30/2021 in the United States. Conclusion This study suggests that substantial reductions in HIV diagnosis rates have occurred in people prescribed PrEP in the US. We found large geographic variations in HIV diagnosis rates, with the largest differences by PrEP prescription status occurring in the Southeast US, underscoring the need for PrEP expansion and its potential impact on the HIV epidemic in that region. Furthermore, our findings demonstrate an approach of estimating HIV rates for PWBP prescribed and those not prescribed PrEP, which may be useful in supporting targeted delivery of HIV prevention services in the US. Disclosures Li Tao, MD, PhD, Gilead Sciences: Employee|Gilead Sciences: Employee|Gilead Sciences: Stocks/Bonds|Gilead Sciences: Stocks/Bonds Jen Thorburn, n/a, Gilead Sciences: Grant/Research Support Amanda Kong, DrPH, Gilead Sciences: Grant/Research Support Debra Irwin, PhD, Gilead Sciences: Grant/Research Support Christoph C. Carter, MD, PhD, Gilead Sciences: Employee|Gilead Sciences: Employee|Gilead Sciences: Stocks/Bonds|Gilead Sciences: Stocks/Bonds Moupali Das, MD, Gilead Sciences: Employee|Gilead Sciences: Employee|Gilead Sciences: Stocks/Bonds|Gilead Sciences: Stocks/Bonds Julie Paone, MPH, Gilead Sciences: Grant/Research Support.

Relative Age and Psychotropic Drug Use in Preterm and Term-Born Children and Young Adults.

Being among the youngest within a school class is linked to disadvantages in various educational and mental health domains. This study aimed to investigate whether preterm born infants are particularly vulnerable to relative age effects on mental health, not previously studied. We used registry data on all Norwegians born between 1989 and 1998 to compare prescription status for psychostimulants, antidepressants, hypnotics, anxiolytics, and antipsychotics per year from age 10 to 23 years (2004-2016) between exposure groups with different time of birth in the year (relative age) and different gestational age (preterm versus term). Of 488 470 individuals, 29 657 (6,1%) were born preterm. For term born in November/December, the adjusted odds ratio (aORs) for psychostimulant prescription compared with peers born in January/February was 1.80 (95% confidence interval [CI], 1.69-1.91) at ages 10 to 14 years, and 1.17 (95% CI, 1.08-1.27) at ages 20 to 23 years. Within preterm born, the corresponding results were 1.39 (95% CI, 1.13-1.69) and 1.34 (95% CI, 1,00-1.78) at ages 10 through 14 and 20 through 23 years, respectively. Being relatively young within the school group was associated with increased psychostimulant prescription in the preterm as well as the term population. In contrast to term peers, the relative age effect for psychostimulant prescription seemed to persist to young adulthood for the preterm population. The results suggest that preterm individuals are vulnerable to long-term effects of relative immaturity and that they require careful consideration from both health care professionals and the school system.

The social determinants of substance use associated with deaths of despair: Individual risks and population impacts

As the incidence of deaths from external causes including poisonings, suicide, and alcohol-related liver disease, increases in countries such as the United States and Canada, a better understanding of the fundamental social determinants of the substance use underlying these so-called “deaths of despair”, at the population level, is needed. Using data from the nationally representative data from the Canadian Community Health Survey (2003, 2015–2016, 2018 cycles) (N = 30,729), the independent associations between age, sex, marital status, immigrant status, race/ethnicity, education, income, rurality, affective health and the use of illicit substances, opioids (without distinction for prescription status), problematic levels of alcohol, and combined past-year use (≥2) of substances, were explored using multivariate logistic regression, marginal risk, and population attributable fraction estimation, with propensity score-adjusted sensitivity analyses. Males, those who were under 29 years, without a partner, born in Canada, White, or had an affective disorder reported both higher use of individual substances and multiple substances in the past year. Social determinants appear to explain a substantial proportion of substance use patterns overall. Between 10% and 45% of illicit substance, problematic alcohol, and polysubstance use prevalence was attributable to non-partnered marital status, non-immigrant status, and White race/ethnicity. Of opioid use prevalence, 25% was attributable to White race/ethnicity, 13% to affective disorder status and 4% to lower-income. Though not all substance use will result in substance-related morbidity or mortality, these findings highlight the role of social determinants in shaping the intermediary behavioural outcomes that shape population-level risk of “deaths of despair”.

Inhibition of sodium-glucose cotransporter 2 suppresses renal stone formation

Background and aimsNephrolithiasis is a common renal disease with no effective medication. Sodium-glucose cotransporter-2 (SGLT2) inhibitors, an anti-diabetic agent, have diuretic and anti-inflammatory properties and could prevent nephrolithiasis. Here, we investigated the potential of SGLT2 inhibition against nephrolithiasis using large-scale epidemiological data, animal models, and cell culture experiments. MethodsThis study included the data of diabetic patients (n = 1,538,198) available in the Japanese administrative database and divided them according to SGLT2 inhibitor prescription status. For animal experiments, renal calcium oxalate stones were induced by ethylene glycol in Sprague-Dawley rats, and phlorizin, an SGLT1/2 inhibitor, was used for the treatment. The effects of SGLT2-specific inhibition for renal stone formation were assessed in SGLT2-deficient mice and a human proximal tubular cell line, HK-2. ResultsNephrolithiasis prevalence in diabetic men was significantly lower in the SGLT2 inhibitor prescription group than in the non-SGLT2 inhibitor prescription group. Phlorizin attenuated renal stone formation and downregulated the kidney injury molecule 1 (Kim1) and osteopontin (Opn) expression in rats, with unchanged water intake and urine volume. It suppressed inflammation and macrophage marker expression, suggesting the role of the SGLT2 inhibitor in reducing inflammation. SGLT2-deficient mice were resistant to glyoxylic acid-induced calcium oxalate stone formation with reduced Opn expression and renal damages. High glucose-induced upregulation of OPN and CD44 and cell surface adhesion of calcium oxalate reduced upon SGLT2-silencing in HK-2 cells. ConclusionOverall, our findings identified that SGLT2 inhibition prevents renal stone formation and may be a promising therapeutic approach against nephrolithiasis.

Apixaban versus No Anticoagulation by P2Y12 Inhibitor Prescription Status in Dialysis Patients with Atrial Fibrillation.

In patients with atrial fibrillation on dialysis, the incidence of stroke was similar with apixaban or no anticoagulation, regardless of P2Y12 prescription.In patients with atrial fibrillation on dialysis who were on a P2Y12 inhibitor, apixaban increased the risk of bleeding, compared with no anticoagulation.The incidence of myocardial infarction or ischemic stroke was similar with apixaban or no anticoagulation, regardless of P2Y12 prescription status.

Contraception claims by medication for opioid use disorder prescription status among insured women with opioid use disorder, United States, 2018

Objective(s)To understand how contraception method use differed between women prescribed and not prescribed medications for opioid use disorder (MOUD) among commercially-insured and Medicaid-insured women. Study DesignIBM Watson Health MarketScan Commercial Claims and Encounters database and the Multi-State Medicaid database were used to calculate the (1) crude prevalence, and (2) adjusted odds ratios (adjusted for demographic characteristics) of using long-acting reversible or short-acting hormonal contraception methods or female sterilization compared with none of these methods (no method) in 2018 by MOUD status among women with OUD, aged 20 to 49 years, with continuous health insurance coverage through commercial insurance or Medicaid for ≥6 years. Claims data was used to define contraception use. Fisher exact test or χ2 test with a P-value ≤ 0.0001, based on the Holm-Bonferroni method, and 95% confidence intervals were used to determine statistically significant differences for prevalence estimates and adjusted odds ratios, respectively. ResultsOnly 41% of commercially-insured and Medicaid-insured women with OUD were prescribed MOUD. Medicaid-insured women with OUD prescribed MOUD had a significantly lower crude prevalence of using no method (71.1% vs 79.0%) and higher odds of using female sterilization (aOR, 1.33; 95% CI: 1.06–1.67 vs no method) than those not prescribed MOUD. Among commercially-insured women there were no differences in contraceptive use by MOUD status and 66% used no method. ConclusionsAmong women with ≥ 6 years of continuous insurance coverage, contraceptive use differed by MOUD status and insurance. Prescribing MOUD for women with OUD can be improved to ensure quality care. ImplicationsOnly two in five women with OUD had evidence of being prescribed MOUD, and majority did not use prescription contraception or female sterilization. Our findings support opportunities to improve prescribing for MOUD and integrate contraception and MOUD services to improve clinical care among women with OUD.

Clinical characteristics and outcomes of atrial fibrillation patients with peripheral artery disease: the Fushimi AF Registry

Abstract Background Atrial fibrillation (AF) represents the common arrhythmia and increases the risk of thromboembolism. Risk assessment for thromboembolism is important for the management of AF patients. Peripheral artery disease (PAD) is identified as a risk factor for thromboembolism in CHA2DS2-VASc score. However, there are little data on clinical characteristics and cardiovascular events of AF patients with PAD. Purpose In this study, we investigated the clinical characteristics and outcomes of AF patients with PAD. Methods The Fushimi AF Registry, a community-based prospective survey, was designed to enroll all of the AF patients who visited the participating medical institutions in Fushimi-ku, Kyoto, Japan. The inclusion criterion of the registry is the documentation of AF at 12-lead electrocardiogram or Holter monitoring at any time, and there are no exclusion criteria. We started to enroll patients from March 2011 and follow up data including prescription status were available in 4,464 patients from March 2011 to August 2021. Median follow-up period was 1,848 days. Results Of 4,464 patients, 183 patients had PAD (4.1%; PAD group). The mean age was higher in PAD group than no-PAD group (PAD group vs. no-PAD group: 76.7 vs. 73.5; p&amp;lt;0.01). Patients with PAD had more co-morbidities such as stroke, systemic embolism, congestive heart failure, hypertension, diabetes mellitus, dyslipidemia coronary artery disease and chronic kidney disease than those without PAD. Thus, CHADS2 score, CHA2DS2-VASc score and HAS-BLED score were higher in PAD group than no-PAD group (2.81 vs. 2.00; p&amp;lt;0.01, 5.17 vs. 3.30; p&amp;lt;0.01, 2.42 vs. 1.71; p&amp;lt;0.01, respectively). The proportion of patients with oral anticoagulant was similar between the two groups and the proportion of patients with antiplatelet drug was higher in PAD group than no-PAD group (59.0% vs. 55.6%; p=0.36, 62.9% vs. 24.7%; p&amp;lt;0.01, respectively). The incidences of all-cause death, cardiac death and myocardial infarction were higher in PAD group than no-PAD group (11.4 vs. 4.6 per 100 person-years; log-rank p&amp;lt;0.01, 1.7 vs. 0.8 per 100 person-years; log-rank p&amp;lt;0.01, 1.2 vs. 0.2 per 100 person-years; log-rank p&amp;lt;0.01). However, the incidence of stroke or systemic embolism was similar between the two groups (2.9 vs. 2.2 per 100 person-years, log-rank p=0.19). Finally, the incidence of composite of cardiac death, stroke, systemic embolism or myocardial infarction was higher in PAD group than no-PAD group (6.0 vs. 3.0 per 100 person-years; log-rank p&amp;lt;0.01). Conclusion AF patients with PAD had significantly higher risk for death and cardiac events, whereas the incidence of thromboembolism was similar between AF patients with and without PAD. Funding Acknowledgement Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Japan Agency for Medical Research and Development

Impact of Potentially Inappropriate Medications on Kidney Function in Chronic Kidney Disease: Retrospective Cohort Study

Introduction: Chronic kidney disease (CKD) represents a major public health burden. Potential inappropriate medications (PIMs) are common in patients with CKD. However, its impact on kidney outcomes has not been adequately elucidated for middle-aged patients. This study aimed to clarify the prescription status of PIMs for middle-aged patients with CKD and its effect on kidney function decline. Methods: Using an administrative claims database in Japan, a retrospective cohort study was conducted among Japanese patients with CKD (aged 20–74) who underwent annual health check-ups at least three times between April 2008 and December 2020. PIM exposure was defined as medications to be avoided in older adults as defined by the 2019 American Geriatrics Society Beers Criteria. The association between the number of prescribed PIMs and the decline in estimated glomerular filtration rate (eGFR) was examined using logistic regression models adjusted for clinical characteristics and laboratory variables. Results: A total of 43,143 patients with CKD (mean age 57 years, median eGFR: 52 mL/min/1.73 m2) were analyzed, and approximately 40% of the patients were prescribed one or more PIMs. The most commonly prescribed PIMs were pain medications (18.5%), followed by gastrointestinal medications (9.8%), central nervous system medications (8.6%), and cardiovascular medications (8.6%). After adjustment, exposure to 2 or ≥3 PIMs was associated with an increased risk of 30% eGFR decline (adjusted odds ratio 1.71 [95% confidence interval, 1.24–2.37] and 1.65 [95% confidence interval, 1.08–2.52], respectively) as compared to the control group. Conclusion: This study showed that middle-aged patients with CKD who were prescribed ≥2 PIM had an increased risk of progression of CKD. Further studies are needed to analyze whether deprescribing steps contribute to reduce PIM prescriptions and prevent CKD progression.

Using Narrative Vignettes to Understand the Misuse and Diversion of Stimulants Among College Students With and Without a Prescription

We used the narrative vignette/storytelling approach to provide a holistic illustration of prescription stimulant misuse [PSM] and diversion [PSD] initiation and maintenance among college-attending emerging adults. We conducted 32 semi-structured, theory-guided interviews with 20 students during spring and summer 2019. The participants were diverse with respect to age, race/ethnicity and gender, and had a history of PSM and/or PSD. We created four narrative vignettes using a multi-step, collaborative process that incorporated patterns of what contributed to initiation and maintenance for four identified student groups (i.e., PSM with and without a prescription and PSD with and without a prescription). Characteristics of the individual, social and broader environments influenced behavior initiation, and positive reinforcement from trial behavior contributed to maintenance. Similarities and differences were identified across the groups. Approaches for PSM and PSD prevention and intervention in college-attending emerging adults should be multifaceted and consider prescription status.

State Diagrams to Understand Failure Pathways in Radiation Therapy: A Case Study of ‘Failure to Hold Treatment’

Aim: A state diagram can be used to map systems and understand processes. Mapping objects (people, tools) and transitions between discrete states increases understanding of the pathways to reach a successful terminal state or a failed state (error or incident). A state diagram was used as part of a case study to investigate an incident where treatment was delivered while radiation treatment was being re-considered. The goal was to explore the ability of this tool to identify radiation therapy practice changes that may reduce or eliminate the potential for treatment to proceed when not intended, or the actions required to hold treatment once a treatment course has commenced. Process: The incident being investigated was a case where all steps were completed for treatment to proceed (treatment plan and prescription were approved), however due to patient co-morbidities and hospital admission, the decision of whether to proceed with treatment was still under consideration when the first fraction of treatment was delivered. To map out the transitions surrounding this event, a state diagram was created. 4 objects and substates were identified: Intention to treat (yes, no, undecided), Patient location (present, absent), Prescription status (none, unapproved, approved) and Plan status (none, unapproved, approved, rejected, discontinued). A composite state diagram was then used to map out the 90 possible combinations of substates including a successful terminal state (intended treatment delivery), and failed states (unintended treatment delivery). Benefits/Challenges: Mapping a system using a state diagram directs attention towards key activities that are required for an error to occur. The goal is to direct process improvement to prevent not only the failed state, but to keep the state of the system more than one step away from the failed state and create barriers or detection mechanisms at these transitions. This tool indicated that some treatment plan status changes require significant rework; treatment prescription changes are low effort but highly dependent on an individual; and that ‘on hold’ status of the plan and prescription is required to make the intention unambiguous. The complexity of a state diagram increases with the number of objects, states, substates and transition pathways. It was necessary to exclude objects that are unreliable or out of programmatic control such as free-text documentation, in person communication, and patient transportation arrangements. Exclusion of these objects to prevent overcomplication was a limitation of the state diagram. Impact/Outcomes: In this case, the state diagram helped to identify 6 states that were one step away from a failed state. Clear identification of these states can be targeted for future process improvement. State diagrams were found to be a useful tool in analyzing the pathways that can lead to unintended radiation treatment delivery and to examine the processes and transitions leading to specific events in radiation therapy.

0475 Prevalence and Potential Benefits of Cannabis Use in Patients with Insomnia

Abstract Introduction Insomnia is highly prevalent amongst patients presenting to sleep centers and it can be challenging to treat. Current treatment modalities include pharmacological intervention and cognitive behavioral therapy. Cannabis use is widely prevalent and has been approved in most states in the United States for medical use. Insomnia has been approved in some states as a qualifying condition for prescribing medical marijuana. Although the sedative effects of cannabis are well known, there are no established clinical guidelines with regards to its use for the treatment of insomnia. Methods We conducted a retrospective chart review to determine the use and potential benefits of cannabis in patients with insomnia over a three-year period at a tertiary care academic center. All patients with cannabis/marijuana and insomnia use listed in their electronic health record were included. Results Our cohort included 159 patients (67 males, 91 females; mean age= 48.4 years) who had a diagnosis of insomnia and used cannabis. 62 out of 159 (39%) patients reported improvement in sleep symptoms, whereas 18 (11.3%) patients denied any improvement. The status of remaining 79 patients (49.7%) was undetermined. 40 patients were African American, 103 were white, 4 were Hispanic; the remaining were of other or unknown ethnicities. 80 (50.3%) patients were using medically prescribed marijuana for various disorders; 50 (31.4%) were using non prescribed cannabis and prescription status was undetermined in 29 (18.2%) patients. Average use of cannabis was 4.9 days per week as reported by 47 patients who used cannabis regularly.50 out of the 62 patients with diagnoses of insomnia and cannabis use who reported improvement in symptoms had a history of comorbid anxiety, whereas 37 of 62 (59.6%) patients had comorbid depression. 29 out of 62 (46.7%) patients were using selective serotonin receptor uptake inhibitors (SSRI) and 24 of 62 (38.7%) were using benzodiazepines. Conclusion Cannabis use is highly prevalent among patients with a diagnosis of insomnia. Patient with cannabis use may have comorbid mood and anxiety disorders and may be taking SSRIs or benzodiazepines. Sleep physicians need to be aware of cannabis use and its impact on sleep symptoms in patients with insomnia. Support (If Any)

An audit to determine how teratogenic risks of carbimazole are considered for patients of child-bearing potential in an acute hospital setting

Abstract Introduction Carbimazole is associated with an increased risk of congenital malformations when used in pregnancy. In 2019, the Medicines and Healthcare products Regulatory Agency (MHRA) strengthened its advice on risk minimisation (1). The valproate national campaign raised awareness of risks amongst healthcare professionals and the public (2). However, within our organisation it was perceived that awareness of teratogenic effects of carbimazole was potentially less well-known. Aim The aim was to determine if teratogenic risks associated with carbimazole were considered in patients of child-bearing potential. Objectives were to measure the percentage of patients that had a documented: acknowledgement of risk (audit standard 70%); pregnancy or contraception status (audit standard 80%); record of provision of patient information (audit standard 70%) and make recommendations to improve practice. Methods An audit approach was used with standards derived from national guidance (1). The setting was an acute NHS organisation comprising two main sites. The prescribing, health record (HR) and pharmacy dispensing systems were electronic. A cluster sample of female patients aged ≤45 years that had carbimazole dispensed between November 2018 and November 2019 were included. A data collection tool was developed and piloted prior to use. A trainee pharmacist reviewed patient HRs and extracted details of prescription, risk conversations, contraception and pregnancy status onto the data collection tool. Patients without a consultation record were excluded. No patient or staff identifiable data were recorded. Data were collated using Microsoft Excel and analysed descriptively. Results Seventy-nine of 81 patients aged 11-45 years were included; two patients were excluded because their consultation records were unavailable. Of 79 patients, 35 (44%) had either pregnancy status, contraception, teratogenic risk consideration or discussion documented. For 44 (56%) patients, there was no documented acknowledgement of risk. Twenty-nine (36%) patients had their pregnancy or contraception status documented. For six pregnant patients, provision of advice was unclear. Only fifteen (19%) had specific documentation about risk consideration and six of documented risk conversations with patients. There was no evidence pharmacists had checked risk considerations made by prescribing clinicians or actively provided information to patients. Conclusion Findings suggest that consideration of teratogenic risk of carbimazole is inconsistent. Where pregnancy and contraception status were documented in the absence of further information, it was unclear if patients were informed of risks or involved in treatment discussions. Findings have limited generalisability due to the small sample. Although HR were thoroughly reviewed, findings were based on documentation that was potentially incomplete or not representative of detailed discussions during patient consultations. Further research should use methods to explore clinician and patient awareness of teratogenic risk of carbimazole and patient involvement in their treatment decisions. Recommendations are to: upskill pharmacists so they more actively provide risk information; better utilise electronic prescribing to mandate inclusion of contraception status and facilitate standardised risk consideration. National bodies should implement formal risk minimisation strategies for all teratogenic drugs. References (1) Medicines and Healthcare products Regulatory Agency. Carbimazole: increased risk of congenital malformations strengthened advice on contraception [internet]. London: MHRA; 2019 [cited February 2019]. Available from: https://www.gov.uk/drug-safety-update/carbimazole-increased-risk-of-congenital-malformations-strengthened-advice-on-contraception (2) NHS England and NHS Improvement. Patient Safety Alert Resources to support the safety of girls and women who are being treated with valproate [internet]. London: NHSEI; 2017 [updated 2019 December 6]. Available from https://www.england.nhs.uk/wp-content/uploads/2019/12/Patient_Safety_Alert_-_Resources_to_support_safe_use_of_valproate.pdf