Prescription Rates Research Articles

Assessment of Clinical Outcomes and Pain Management of Single-Level Lumbar Laminectomy Between Unilateral Biportal Endoscopic, Tubular, and Open Approaches

Objective: While minimally invasive surgical procedures have been shown to reduce postoperative pain and recovery time compared to an open surgical approach, few studies have also compared pain management, particularly involving the use of unilateral biportal endoscopy (UBE). Methods: Patients who underwent single-level laminectomy through a UBE, open, or tubular technique were chart-reviewed for up to 90 days for perioperative outcomes, including opioid and nonopioid utilization. The chi-square test and analysis of variance were used to analyze differences in characteristics and outcomes between groups. The post hoc Tukey test and multinomial regression were conducted when significance was found in initial tests.Results: In total, 184 patients were included in the study (110 open, 44 tubular, 30 UBE). The UBE patients were the oldest. Post hoc analysis showed that UBE and tubular patients had significantly lower blood loss than the open group (p<0.05). Moreover, UBE surgery was associated with significantly longer operative times than both tubular and open surgery (p<0.05). No significant differences were observed in complications, 90-day readmissions, or return to the operating room. Postdischarge, patients in the open and tubular groups had higher rates of acetaminophen and cyclobenzaprine prescriptions, respectively, than the UBE group (p<0.05). Postoperative opioid use at 2 weeks significantly differed among groups. When controlling for age and preoperative opioid use, multivariate regression revealed that patients who underwent decompression by UBE had lower odds of postdischarge opioid use at 2 weeks than the open group (53.20% vs. 21.70%; odds ratio [OR], 0.267; 95% confidence interval [CI], 0.09–0.79; p=0.017) and the tubular group (50.0% vs. 21.70%; OR, 0.268; 95% CI, 0.08–0.91; p=0.038). No statistically significant between-group differences were observed for ongoing opioid use at the 6-week and 3-month time points.Conclusions: Patients who underwent UBE had significantly lower odds of postdischarge narcotic use at 2-week follow-up than those undergoing the open and tubular approaches.

Impact of Education on Inappropriate Antibiotic Prescription for Respiratory Tract Infection Based on Physicians' Justifications: A Web-Based Survey in Japan.

Background: Antibiotics are inappropriately prescribed for respiratory tract infections for various reasons. The differences of the effects of education based on these reasons has not been fully elucidated. This study assessed the impact of an educational film on antibiotic prescription patterns according to physicians' prescribing justifications. Methods: This was a secondary analysis of a nationwide web-based survey involving 1100 physicians. The physicians were required to view a short educational film and determine the need for prescribing antibiotics in simulated scenarios of different acute respiratory tract infectious diseases. The associations between the reasons for antibiotic prescription to patients not requiring antibiotics before viewing the educational film and the positive effects of the intervention were analyzed. Results: The educational intervention positively affected prescribing trends among physicians who prescribed antibiotics for "fever" in mild acute rhinosinusitis (prescription rates from 100% to 25.9%), "pus in the laryngopharynx" in mild acute pharyngitis (prescription rates from 100% to 29.6%), and "purulent sputum" in acute bronchitis without chronic lung disease (prescription rates from 100% to 29.9%) before viewing the film. In contrast, no benefits were observed when the justification was "patient's desire for antibiotics" in mild acute pharyngitis (prescription rates from 100% to 48.5%) and acute bronchitis without chronic lung disease (prescription rates from 100% to 44.0%) or "parents' desire for antibiotics" in narrowly defined common cold in children (prescription rates from 100% to 45.7%). Conclusions: although educational interventions might reduce inappropriate antibiotic prescription by providing accurate knowledge about respiratory tract infections, they appear ineffective for physicians who prescribe antibiotics based on patients' or parents' desires for antibiotic treatment.

At-home Administration of Opioid Analgesia in Children After Reduction of Forearm Fracture.

Controversy exists surrounding which agents best provide analgesia in children with fractures. Prior studies have demonstrated that ED visits for fracture-related pain have the highest rates of opioid prescribing. Studies have also found that NSAIDs are equivalent at controlling acute fracture-related pain. In a time when one must balance the risk of inadequate pain control with potential opioid misuse, providers have little data to guide them in terms of the best recommendations for adequate pain control at home. This prospective observational study investigates parental pain management practices after ED discharge for children who underwent a forearm fracture reduction. Surveys filled out by parents were used to gather data on the proportion of children discharged with an opioid prescription, the number of doses of opioid that were administered after discharge, and parental satisfaction with their child's pain control. We analyzed data for 61 patients who completed the postdischarge survey. Of these, 62% received a prescription for oxycodone at discharge, and 50% used at least 1 dose of oxycodone at home. The median number of doses administered at home, 1.5 (IQR, 0-3), was significantly lower than the number of doses of oxycodone prescribed, 10 (IQR, 5-12) (P < 0.001). Parents reported a high level of satisfaction with the medications received at discharge with nearly all ranging between 4 (satisfied) and 5 (very satisfied) (median, 5; IQR, 4-5). No significant difference was detected in the satisfaction between families who received a prescription for oxycodone at discharge (median, 5; IQR, 4-5) and those who did not (median, 5; IQR, 4-5) (P = 0.28). We observed a large range in the number of doses of oxycodone prescribed at discharge and a significant difference between the number of doses being prescribed and those being used by families. A prescription of 2 doses of oxycodone would be sufficient to treat postreduction pain in the majority of children.

Clinical practices and treatment preferences in chronic coronary syndrome management among Indian physicians

Introduction: Chronic coronary syndrome (CCS) is a significant contributor to morbidity and mortality worldwide, particularly in India, where risk factors such as hypertension and diabetes are increasingly prevalent. Effective management of CCS typically involves lifestyle modifications, pharmacotherapy, and sometimes interventional procedures. Methods: A digital questionnaire-based survey was conducted across multiple sites in India, involving cardiologists and consultant physicians. The survey comprised nine questions addressing the prevalence of CCS, preferred treatments, and factors influencing prescribing decisions for novel oral anticoagulants (NOACs). Results: A total of 66 physicians were enrolled. Approximately 40.30% of physicians reported that more than 40% of their patients had CCS. The majority of physicians (57.81%) reported that dual antiplatelet therapy (DAPT) was most preferred treatment for CCS. Around 51% of physicians reported bleeding risk as the primary hindrance in prescribing rivaroxaban and aspirin for CCS patients. The majority of physicians (42.19%) preferred rivaroxaban with a prescription rate of 40%. Apixaban was most commonly prescribed at a rate of 30% by 33.87% of physicians, while dabigatran was typically prescribed at rates of 10% and 20% (41.82% each). Warfarin was prescribed for 10% of patients by 51.79% of respondents. In non-valvular atrial fibrillation cases, 73.13% preferred rivaroxaban primarily for its once-daily dosing advantage. Conclusion: The present study reveals current trends in the management of CCS and the utilization of NOACs among physicians in India. It underscores the growing significance of NOACs, particularly rivaroxaban, in enhancing treatment outcomes for patients with CCS.

The Effect of Obesity on Postoperative Analgesia Practices and Complications Following Endoscopic Sinus Surgery: A Propensity Score-Matched Cohort Study.

Despite growing concern regarding over-prescription of narcotic pain medication following ambulatory surgery, little is known about the analgesic prescribing practices following endoscopic sinus surgery (ESS) in obese patients in comparison to non-obese patients. To compare the rates of opioid versus non-opioid prescriptions, the need for steroids, and post-operative adverse events between obese and non-obese adult patients undergoing ESS. Using TriNetX Live database, we identified all patients aged ≥18 years who underwent ESS (n = 1303) between 2014 and 2022 across several healthcare institutions across the state of Tennessee. We 1:1 propensity score-matched obese (BMI ≥ 30 kg/m2) and non-obese (18.5 kg/m2 ≤ BMI < 30 kg/m2) cohorts for age, gender, race, and comorbidities including asthma, nicotine dependence, and sleep apnea. Rates of prescriptions and post-operative adverse events between cohorts were analyzed using risk ratios (RR) and confidence intervals (CI). A toal of 532 obese patients were compared to 532 propensity score-matched non-obese patients in the first 14 post-operative days following ESS. The obese cohort was significantly more likely to be prescribed analgesics generally (RR = 1.72; 95% CI = 1.20-2.47), non-opioid analgesics (RR = 1.73; 95% CI = 1.19-2.50), and opioid analgesics (RR = 1.64; 95% CI = 1.14-2.36) than non-obese patients. There was no difference in rates of antibiotic or antiemetic prescription, prednisone/methylprednisolone, dexamethasone, ED visits, critical care service, epistaxis, transfusion, anemia, revision sinus surgery, mechanical ventilation, CPAP, or inhalation airway treatments. Obese patients undergoing ESS were significantly more likely to be prescribed non-opioid and opioid analgesia in the first 14 days post-operatively compared to non-obese patients. There were no differences in post-operative adverse events or other prescriptions. Otolaryngologists should be aware that obese patients are at increased risk of opioid induced airway obstruction and steroid induced hyperglycemia, especially in patients with comorbid sleep apnea or diabetes. Emphasis on non-opioid analgesics and multimodal pain management should be advocated for this population.

Guideline-directed medical therapy patterns in heart failure with reduced ejection fraction: the OPTIMA-HF registry

Abstract Background/Introduction European guidelines strongly recommend an optimized pharmacological treatment in patients with heart failure with reduced ejection fraction (HFrEF) with a fast introduction of the four-pillars. Purpose Aim of the Optimization of Therapy in the Italian Management of Heart Failure [OpTIMa-HF] Registry was to collect data on HF patients to describe the current Italian population of HF patients with a specific focus on HFrEF treatment adherence and prescription rates, according to the most recent European Guidelines. Methods OPTIMA-HF is an observational, cross-sectional, multicenter, real-life study conducted in two different clinical settings: HF outpatients’ clinics of Italian University Hospitals and territorial Italian Cardiology outpatients’ services, that enrolled patients with chronic HFrEF receiving at least 1 oral medication for management of HF. Patients were characterized by baseline use and dose of angiotensin-converting enzyme inhibitor (ACEI)/angiotensin II receptor blocker (ARB)/angiotensin receptor neprilysin inhibitor (ARNI), beta-blocker, mineralocorticoid receptor antagonist (MRA) and sodium glucose co-transporter II inhibitor (SGLT2i). Patient-level factors associated with medication use were examined. Results Overall, 1390 patients from 29 ambulatory cardiology practices and university hospitals were included. Mean age was 69.5 ± 11.9 years, 24% were female, and median EF was 33 (28-37). Among enrolled patients, 72.2% were prescribed ARNI, 17.1% ACEI/ARB, 95% beta-blocker, 75.5% MRA and 63% SGLT2i therapy (Figure 1). Despite high prescription rates for each single class, a still not sufficient number of patients was on treatment with all four pillars, in particular 40.4% considering the presence ARNI and 6.2%. When medications were prescribed, few patients were receiving target doses of ACEI/ARB (31.7%), ARNI (16%), and beta-blocker (33.3%), whereas a higher proportion were receiving target doses of MRA therapy (38%), and all were receiving target dose for SGLT2i. Among patients eligible for all classes of medication, only 1.1% were simultaneously receiving target doses of ACE/ARB/ARNI, beta-blocker, MRA and SGLT2i. Prescription rates did not significantly differ between the type of center (University Hospital vs. territorial Cardiology outpatients’ services). As regards patients not on treatment with any of the four pillars, a small but still present amount of patients had no contraindications to these drugs (Figure 1). Conclusions In this contemporary outpatient HFrEF Italian registry, significant high prescription rates of the four-pillars were observed, however therapy combination rate is still not sufficient and drugs' titration need to be implemented to receive the greatest benefits from an optimized treatment. Strategies to improve guideline-directed use of HFrEF medications remain urgently needed, and these findings may inform targeted approaches to optimize outpatient medical therapy.

Comparing PCSK9 inhibitor prescription rates within high-risk populations: diabetes mellitus, multi-territory vascular disease, multivessel and recurrent coronary artery disease

Abstract Background Proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors are subsidised in Australia for treatment of hypercholesterolemia in particularly high-risk patients with atherosclerotic cardiovascular disease (ASCVD). These high-risk groups are defined as: diabetes mellitus (with age≥60, Aboriginal or Torres Strait Islander origin or microalbuminuria), recurrent ASCVD (≥2 events within 5 years), multivessel coronary disease (≥50% stenosis in ≥2 large vessels) and multi-territory vascular disease (concurrent cerebrovascular or peripheral vascular disease). Methods A retrospective observational analysis was conducted on high-risk patients with LDL&amp;gt;2.6 admitted to a quaternary hospital with ASCVD between 2020-2022. Australian Pharmaceutical Benefits Scheme (PBS) criteria was applied to assess and compare PCSK9 inhibitor eligibility and prescription rates within high-risk populations. Results In total, 477 ASCVD patients with LDL&amp;gt;2.6 were included. This was further categorised into: multivessel coronary disease (n=239, 50.1%), diabetes mellitus (n=60, 12.6%), recurrent ASCVD (n=55, 11.5%) and multi-territory vascular disease (n=32, 6.7%), p&amp;lt;0.001. When 2020 PBS criteria was applied, the number of eligible patients were 16/239 (6.7%), 5/60 (8.3%), 13/55 (23.6%) and 4/32 (12.5%) respectively, p=0.002. Of PBS eligible patients, the number prescribed PCSK9 inhibitors were: 7/16 (43.8%) for multi-vessel coronary disease, 1/5 (20%) for diabetes mellitus, 4/13 (30.8%) for recurrent ASCVD and 1/4 (25%) for multi-territory vascular disease patients (p=0.73). Conclusion Although there was a significantly higher prevalence and proportion of eligible multivessel coronary disease patients, prescribing rates for PCSK9 inhibitor therapy remain low amongst all high-risk eligible groups including diabetes mellitus, multi-territory vascular disease, multivessel and recurrent coronary artery disease.

Temporal trends of prescription rates, dosing of non-vitamin K antagonist oral anticoagulants and clinical outcomes in patients with atrial fibrillation

Abstract Background The launch of non-vitamin K antagonist oral anticoagulant (NOAC) has revolutionized the landscape of stroke prevention in atrial fibrillation (AF). We aimed to analyze the temporal trends of prescription rates of oral anticoagulants (OACs), NOAC dosing, clinical outcomes and in patients with AF. Methods This was a retrospective study using the Taiwan National Health Insurance Research Database. During 2011 to 2020, A total of 249,107 patients aged ≥30 years with newly diagnosed AF were identified. We analyzed the 1-year risks of ischemic stroke, intracranial hemorrhage (ICH), and all-cause mortality for overall population and specifically for NOAC users. Results The prescription rate of OAC increased from 22.1% in year 2011 to 57.7% in 2020 (P&amp;lt;0.001) with NOAC accounting for 91.0% of overall OAC prescriptions. Compared to patients with incident AF diagnosed in 2011, there were increasing trends for a greater decrease in the risks of ischemic stroke (adjusted hazard ratios [aHRs] 0.914 in 2012, 0.879 in 2013, 0.925 in 2014, 0.822 in 2015, 0.754 in 2016, 0.763 in 2017, 0.769 in 2018, 0.713 in 2019 and 0.707 in 2020; all P&amp;lt;0.05) and mortality (aHRs 0.903 in 2014, 0.899 in 2015, 0.830 in 2016, 0.808 in 2017, 0.788 in 2018, 0.810 in 2019, 0.788 in 2020; all P&amp;lt;0.05), while the risk of ICH did not change significantly (Figure 1). For NOAC users, the percentages of high-dose NOACs increased from 11.04% in year 2012 to 44.29% in year 2019 to 2020. The increasing trend in the use of high-dose NOACs was temporally associated with a lower risk of ischemic stroke observed for patients receiving NOACs in year 2015 to 2017 (aHR 0.794) and year 2018 to 2020 (aHR 0.688) compared to those in year 2012 to 2014 (Figure 2). Conclusion In this nationwide cohort study, there was an increasing trend of OAC prescription, temporally associated with a decline of the risk of ischemic stroke and mortality. Even among NOACs users, the risk of ischemic stroke declined gradually, partly explained by the increasing prescriptions of high-dose NOACs.

Temporal trends in lipid management among Korean patients following acute myocardial infarction from 2011 to 2020

Abstract Background/Purpose Real-world data trends on dyslipidaemia prevalence and lipid management for patients following acute myocardial infarction (AMI) are lacking in South Korea, one of the Asia-Pacific nations. Our study aimed to evaluate the 10-year temporal trends of dyslipidaemia prevalence and lipid management in this patient population. Methods The study utilized datasets from two Korean AMI observational cohort (2011–2020) including a total of 26,751 participants (Figure 1A). The primary endpoints were as follows: (1) absolute low-density lipoprotein cholesterol (LDL-C) target of &amp;lt;70 mg/dL; (2) relative LDL-C target of &amp;gt;50% LDL-C reduction from the baseline; (3) absolute or relative LDL-C target (American target); and (4) both absolute and relative LDL-C targets (European target). Results The prevalence of dyslipidaemia increased from 11.1% to 17.1% (Table 1, Figure 1B), while the statin prescription rates increased from 92.9% to 97.0% from 2011 to 2020. High-intensity statin use increased from 12.80% in 2012 to 69.30% in 2020 (Table 1) Interestingly, the yearlong substantial increases in the prescription rates of high-intensity statins were prominent between 2013 (21.9%) and 2014 (37.7%) and between 2018 (52.4%) and 2019 (66.1%), which may have been influenced by major revisions to the international lipid management guidelines and their adoption (Figure 1C). Ezetimibe use increased from 4.50% in 2016 to 22.50% in 2020. The achievement rate of the absolute and relative LDL-C targets increased from 41.4% and 20.8% in 2012 to 62.5% and 39.5% in 2019, respectively (Table 1). The achievement rates of the American (45.7% in 2012 to 68.6% in 2019) and European (16.5% in 2012 to 33.8% in 2019) targets showed similar increasing trends (Table 1, Figure 1D). Conclusions Despite the adoption of lipid management guidelines in clinical practice has improved, some patients some patients are unable to reduce their LDL-C concentrations to their target levels. Our real-world analyses emphasise the need for multidirectional and continued efforts to optimise lipid management and improve the clinical outcomes in these patients.Figure 1

Unique regional risk profiles and cardiovascular outcomes of patients with acute coronary syndrome in the absence of standard modifiable risk factors: a systematic review and meta-analysis

Abstract Background With differences in prevalence, risk profile, cardiovascular complications, and mortality of patients with acute coronary syndrome (ACS) in the absence of standard modifiable risk factors (SMuRF-less) worldwide, this study examines the regional differences and the unique risk profiles of this often-understudied group of patients. Purpose We hypothesize that differences in non-traditional risk factor profiles may lead to unique ACS-related presentations, complication rates, and secondary preventative strategies across regions. Hence this study was undertaken to assess the cross-regional comparisons of patient characteristics, risk profile, angiographic characteristics that may provide insights into disparate cardiovascular outcomes observed in the SMuRF-less ACS population. Methods Medline and Embase databases were searched in November 2022 to identify relevant literature relating to the prevalence of risk factors in SMuRF-less patients with ACS. A single-arm meta-analysis of proportion and means was conducted on baseline and presentation characteristics, outcomes and complications, management, and risk factors in SMuRF-less ACS patients, stratified according to geographical region (Asia-Pacific, Europe, and North America). Risk of bias was assessed using the Newcastle-Ottawa scale. Results A total of 25 studies comprising of 1,393,184 individuals with ACS were included, of which 242,929 patients were SMuRF-less. Within this SMuRF-less ACS group, mortality rates were similar across the regions (Asia-Pacific:15.8%, Europe:17.5%, p=0.861), cardiac arrest (6.3%, 95%CI:2.3% to 16.3%, p=0.001) and major bleeding (5.2%, 95%CI:2.9% to 9.2%, p=0.001) were more prevalent in Asia-Pacific, and heart failure more common in Europe (21.7%, 95%CI:18.2% to 25.7%, p&amp;lt;0.001). Prevalence of chronic obstructive lung disease (21.4%, 95%CI:21.2% to 21.6%, p&amp;lt;0.001) and peripheral artery disease (3.8%, 95%CI:3.1% to 4.7%, p=0.001) were highest in SMuRF-less ACS patients from North America, chronic liver disease most prevalent in those from Asia-Pacific (3.5%, 95%CI:2.2% to 5.6%, p&amp;lt;0.001) and family history of coronary artery disease highest in SMuRF-less ACS patients from Europe (25.2%, 95%CI:24.8% to 25.7%, p=0.024). Significantly lower rates of guideline-directed medical therapy prescriptions were observed for SMuRF-less ACS patients in Asia-Pacific compared to other regions. Conclusion This regional analysis highlights the different risk profiles, cardiovascular outcomes, and specific needs of individuals presenting with ACS in the absence of cardiovascular risk factors, across Asia-Pacific, Europe, and North America. Whilst unravelling novel pathomechanistic pathways of atherosclerosis will prove beneficial on a global scale, understanding the unique regional profile of these individuals will aid policymakers strategize effective and tailored clinical pathways in the management of SMuRF-less ACS.Graphical AbstractKey Outcomes

Effect of severe tricuspid regurgitation on the prognosis of patients with atrial functional mitral regurgitation: the REVEAL-AFMR registry

Abstract Background Tricuspid regurgitation (TR) often coexists with atrial functional mitral regurgitation (AFMR), resulting from tricuspid annular dilatation by right atrial enlargement/dysfunction without balanced leaflet area enlargement. The clinical impact of TR coexisting with AFMR have not been well understood. Purpose We aimed to investigate the prevalence and prognostic value of TR coexisting with AFMR. Methods In 26 facilities in Japan, patients with AFMR defined with significant functional MR with dilated left atrium and preserved left ventricular ejection fraction were enrolled. The primary endpoint was all-cause death, and the secondary endpoints were the composite of all-cause death and re-hospitalization for HF readmission. Results We analyzed 829 cases (age 77±9 years, 55% male) with moderate or severe AFMR excluding moderate or greater valvular stenosis and severe valvular regurgitation. Of these, 14.5% (n=120) had severe TR. The prevalence of severe TR increased as the severity of AFMR worsened (Figure A). Patients with severe TR had a longer history of atrial fibrillation, elevated NT-proBNP levels, a higher rate of prior heart failure hospitalizations, and a higher rate of prescription of loop diuretics than those with non-severe TR. There were no significant differences in tricuspid annular plane systolic excursion (TAPSE) and right ventricular S′ between the groups. In a multivariate logistic regression analysis, existence of atrial fibrillation and its duration, and higher right atrial pressure were independent determinants of severe TR. Kaplan-Meier curves showed prognostic stratification by severe or non-severe TR for both all-cause mortality and the composite endpoints (p&amp;lt;0.001). Severe TR was significantly associated with both all-cause deaths and the composite endpoints after adjusted for covariates regardless of the severity of MR (adjusted hazard ratio (HR) 1.74 [95% confidence interval 1.05-2.87], p=0.031 for all-cause deaths and adjusted HR 1.54 [1.03-2.30], p=0.033 for the composite endpoints) (Figure B). Conclusion Severe TR was associated with increased adverse events in patients with AFMR, independently of the severity of MR.

Competitive Bidding and Rate of Prescriptions for Home Oxygen

Competitive Bidding and Rate of Prescriptions for Home Oxygen

Glucose lowering drugs with proven cardiovascular benefit following acute coronary syndrome in type 2 diabetes: treatment gaps and outcomes

Abstract Background and Aims Real-world data on the implementation and prognostic impact of glucose-lowering drugs with proven cardiovascular benefits in patients with type 2 diabetes (T2D) following acute coronary syndromes (ACS) is limited. We investigated the utilization and treatment patterns of sodium-glucose contrasporter-2 inhibitors (SGLT2I) and glucagon-like peptide-1 receptor-agonists (GLP1RA) in T2D patients experiencing ACS, and analyzed their association with mortality and major adverse cardiovascular events (MACE) including recurrent ACS, acute revascularization, heart failure or ischemic stroke. Methods Retrospective analysis of 9,756 patients with T2D from a nationwide healthcare organization hospitalized with ACS between 01/2019 and 01/2022. Drug prescriptions were estimated pre-hospitalization, 90-days and 1-year following hospitalization. The association between SGLT2I and/or GLP1RA treatment with MACE and mortality was investigated using time-dependent Cox regression analysis with multivariable adjustment. Results Prescription rates (prehospitalization, 90-days and 1-year posthospitalization) of GLP1RA were 13%, 13.2%, and 18%, and of SGLT2I were 23.9%, 33.6% and 42.7%, respectively. At 1-year, 13.9% prescribed both therapeutic groups. The use of SGLT2I and/or GLP1RA was higher in younger age-groups, and increased from 2019 to 2021 (38.1% to 59.2%). The adjusted hazard ratio for the association of pre- or post-hospitalization SGLT2I and/or GLP1RA treatment with mortality and MACE was 0.724 (0.654-0.801) and 0.974 (0.909-1.043), respectively. Conclusions In real-world practice of patients with T2D experiencing ACS, implementation of SGLT2I and particularly GLP1RA was suboptimal, both early and 1-year following hospitalization, emphasizing the need to improve medical care. Treatment with SGLT2I and/or GLP1RA was associated with favorable impact on mortality but not MACE.Graphical Abstract

Supplemental Oxygen Use, Outcomes, and Spending in Patients With COPD in the Medicare Competitive Bidding Program

The Medicare Competitive Bidding Program (CBP), a policy that reduced durable medical equipment prices, was implemented starting in 2011. Legislation introduced in 2024 aims to remove supplemental oxygen from the CBP because of concerns that recent decreases in oxygen prescribing are due to lower prices set by the CBP, which may have decreased supply and, in turn, limited oxygen access for patients with chronic lung diseases. However, low-value prescribing of oxygen is also prevalent in practice, and decreased oxygen prescription rates may not have necessarily caused harm. Little is known about the association of the CBP with patient use, outcomes, or spending. To examine the association between the 2011 and 2013 implementation of the CBP and supplemental oxygen use, clinical outcomes, and supplemental oxygen spending among patients with chronic obstructive pulmonary disease (COPD). This cohort study used a difference-in-differences (DID) method to evaluate the association between implementation of the CBP and the outcomes of interest. Patients aged 65 to 100 years with COPD living in CBP areas were compared with those living in areas where the CBP was not yet or never implemented. The study included 100% fee-for-service Medicare data of beneficiaries enrolled between July 1, 2009, and December 31, 2015. The data analysis was performed between June 6, 2023, and August 16, 2024. The 2011 and 2013 implementation cycles of the Medicare CBP. The primary outcomes were new prescriptions of oxygen during a 6-month period among beneficiaries with COPD and discontinuation of oxygen during a 6-month period among beneficiaries with COPD previously prescribed oxygen. Secondary outcomes included switches between oxygen types (gas, liquid, or concentrator), all-cause mortality, all-cause unplanned hospitalizations, COPD hospitalizations, and mean monthly allowed charges (total spending) over a 6-month period. The analysis was performed using the Callaway-Sant'Anna method, a dynamic DID model for policies with staggered implementation. Among 5 753 308 Medicare beneficiaries with COPD (mean [SD] age, 79.2 [8.4] years; 55.1% female), 25.9% received supplemental oxygen for at least one 6-month period during the study. The CBP was not associated with differential changes in new oxygen prescribing (DID estimate, -0.19 percentage points; 95% CI, -2.45 to 2.08 percentage points) or oxygen discontinuations (DID estimate, -0.77 percentage points; 95% CI, -8.15 to 6.60 percentage points). Similarly, differential changes were not observed in the secondary outcomes of oxygen switches (DID estimate, -0.04 percentage points; 95% CI, -0.44 to 0.37 percentage points), all-cause mortality (DID estimate, 0.16 percentage points; 95% CI, -7.52 to 7.84 percentage points), all-cause unplanned hospitalizations (DID estimate, -0.20 percentage points; 95% CI, -10.94 to 10.53 percentage points), or COPD hospitalizations (DID estimate, -0.04 percentage points; 95% CI, -2.57 to 2.48 percentage points). Differential changes were observed for mean monthly allowed charges (DID estimate, -$326.22; 95% CI, -$434.76 to -$217.68). In this study, among beneficiaries with COPD, the Medicare CBP was associated with differentially lower spending but not differential changes in oxygen use or clinical outcomes. This study did not find evidence supporting ongoing policy efforts to remove supplemental oxygen from the CBP.

Prognostic implications of p2y12 inhibitor pre-treatment in non-st segment elevation acute coronary syndromes undergoing late invasive strategy - a national registry analysis

Abstract Background Current guidelines recommend considering P2Y12 pre-treatment (PreT) in patients (pts) with non-ST segment elevation acute coronary syndrome (NSTE-ACS) expected to undergo a late invasive strategy, based on individual bleeding risk. Purpose Investigate in-hospital morbidity and mortality in NSTE-ACS pts undergoing a late invasive strategy (coronary angiography (CAG) performed &amp;gt;24h post-admission) comparing those receiving P2Y12 inhibitors (P2Y12i) PreT with those who did not. Methods Retrospective multicenter analysis of NSTE-ACS pts from the Portuguese Registry on Acute Coronary Syndromes (ProACS) undergoing a late invasive strategy from October 2010 to October 2023. Exclusion criteria: previous treatment with P2Y12i or anticoagulants; atrial fibrillation. Two cohorts were defined: pts receiving PreT with P2Y12i before undergoing CAG (group 1) and pts without PreT (group 2). Comparative analyses included baseline characteristics, clinical findings, CAG findings and treatment. Primary outcome was in-hospital major adverse cardiovascular events (MACE), a composite of all-cause mortality, re-infarction, stroke and congestive heart failure. The secondary outcome included individual events and major bleeding. Results 3776 pts were included (mean age:66±12 yrs,29% female), 1530 in group 1 and 2246 in group 2. Group 1 had lower prevalence of dyslipidemia (60 vs 66%, p&amp;lt;0.001), prior stroke (7 vs 5%, p=0.003), myocardial infarction (16 vs 21%) and percutaneous coronary intervention (12 vs 15%) (both p=0.001). On admission, there were no differences regarding Killip-Kimball class (class I - 90 vs 90%,p=0.501) and pts in group 1 less frequently had left ventricular disfunction (left ventricular ejection fraction &amp;lt;50% - 20 vs 24%,p=0.032). Group 1 had higher incidence of obstructive CAD (84 vs 77%,p&amp;lt;0.001), more frequently required more than 1 CAG during admission (8 vs 4%,p&amp;lt;0.001), but multivessel disease did not significantly differ (52 vs 52%,p=0.667). Coronary angioplasty was more frequent in group 1 (63 vs 60%,p=0.019) as was coronary artery bypass graft (13 vs 10%,p=0.002). Regarding anti-thrombotics, group 1 had higher prescription rates of clopidogrel (68 vs 56%), aspirin (99 vs 81%), unfractionated heparin (21 vs 8%), enoxaparin (80 vs 56%), but lower of fondaparinux (12 vs 41%) (all p&amp;lt;0.001). There were no differences in the primary outcome (9 vs 9%,p=0.906) and secondary outcomes: in-hospital mortality (1 vs 1%), re-infarction (1 vs 1%), ischemic stroke (1% vs 0,4%) and congestive heart failure (7% vs 8%) (all p&amp;gt;0.05). Group 1 had higher rates of major bleeding (0.8 vs 0.2%, OR 3.48, CI 95% 1.22-9.89, p=0.013). Conclusions In patients with NSTE-ACS undergoing a late invasive strategy, PreT with P2Y12i showed no statistically significant differences in MACE, despite association with higher rates of major bleeding.Baseline characteristicsPrimary and secondary outcomes

Temporal trends in sudden cardiac death after acute decompensation in HFrEF patients: a 13-year Japanese multicentre registry study

Abstract Background The implementation of guideline-based medical therapy (GBMT) for heart failure with reduced ejection fraction (HFrEF) has significantly contributed to reducing mortality risks. Yet, detailed analyses on temporal trends of sudden cardiac death (SCD) among these patients, especially post-discharge following acute decompensation, remain scarce. Purpose This study aimed to explore changes in the incidence of SCD over the last 13 years in patients with HFrEF discharged after acute decompensation treatment, and to identify clinical factors associated with SCD risk. Methods We analyzed 2,604 consecutive HFrEF (left ventricular ejection fraction [LVEF] ≤40%) patients enrolled in a Japanese multicentre acute heart failure (HF) registry from 2009 to 2021. SCD was defined as an unexpected and otherwise unexplained death in a previously stable patient or death due to documented or presumed cardiac arrhythmia without a clear non-cardiovascular cause. The determination of death cause (SCD, pump failure death, or other) was made by a central adjudicating committee. The Fine and Gray method was employed to analyze factors associated with SCD. The variables submitted to the model included age (≥70 years), gender, LVEF (&amp;lt;30%), ischaemic aetiology and prescription of GBMT (use of renin-angiotensin system inhibitors, β-blockers and mineralocorticoid receptor antagonist) at discharge. Results The mean age of studied patients was 70.9±14.2 years, and 70.0% were male. During the 1-year follow-up period, 262 deaths (10.1%) occurred, including 51 SCDs (2.0%). Older age was associated with an increased risk of SCD (adjusted hazard ratio [HR] 2.81, 95% confidence interval [CI] 1.40-5.64, P=0.004). Further, patients with an ischaemic aetiology had a higher risk of SCD (HR 1.84, 95% CI 1.06-3.22, P=0.032). During the study period, mean age remained constant (71.0 years to 70.7 years, P for trend =0.884). The proportion of ischaemic aetiology also remained constant (from 37.2% to 38.2%, P for trend =0.972). Overall, there were significant decreases in the incidence of all cause death and SCD (from 13.7% to 8.4%, P for trend =0.002; and from 3.5% to 1.0%, P for trend &amp;lt;0.001; Figure A). Notably, there was an increase in the prescription rate of three classes of GBMT at discharge (from 30.9% to 45.6%, P for trend &amp;lt;0.001; Figure B), and the rate of implantable cardioverter-defibrillator (ICD) use in eligible patients (New York Heart Association functional class II-III with LVEF ≤35%) remained constant (from 9.6% to 11.6%, P for trend =0.157; Figure B). Conclusions With the increasing use of GBMT, the incidence of SCD decreased in real-world patients with HFrEF registered in a Japanese acute HF registry over the past decade.

Antipsychotic prescribing practices and their association with rehospitalization in a forensic psychiatric sample.

While there is extensive literature examining the effectiveness of antipsychotic prescribing to patients with schizophrenia spectrum or other psychotic disorders in general psychiatric services, there is a dearth of studies examining antipsychotic prescribing practices and their effectiveness in forensic psychiatric services. Forensic psychiatric patients have unique challenges often due to their high-profile offences, public scrutiny, and legal requirements. This longitudinal, retrospective study aimed to examine antipsychotic prescribing and rehospitalization rates in a forensic psychiatric sample, along with relevant socio-demographic, clinical, and forensic characteristics. All patients had a psychotic illness and were prescribed antipsychotic medication. The sample included 153 patients, of which the majority were male (85.6%), Caucasian (71.2%), middle aged (30s to 50s), had schizophrenia or schizoaffective disorder (76.5%), had a substance use disorder (62.1%), and had a most serious index offence against the person (80.4%). Atypical antipsychotics accounted for the majority of antipsychotic prescriptions (75.9%) and the sample had an antipsychotic polypharmacy rate of 39.9%. The sample was divided into four primary antipsychotic formulation types, which were oral (34.0%), injection (39.2%), clozapine (19.0%), and subtherapeutic (7.8%). Regarding rehospitalization, 52.9% of the sample was rehospitalized, with the average number of rehospitalizations being 1.2 (SD = 1.7) and proportion of the follow up period rehospitalized being 16.4% (SD = 27.7%). Patients prescribed clozapine had numerically lower rates of rehospitalization than those prescribed oral and injection formulation types, but it was not statistically significant. With a 19.0% prescription rate, clozapine may be underutilized in this sample. Further research is needed to demonstrate the potential benefits of clozapine regarding rehospitalization in forensic psychiatric patients, as has already been done in general psychiatry. Advancing treatment of the high-profile forensic population can reduce stigma toward people with mental illness and criminal justice involvement.

Medication Burden Before and After Prescription of Biologics in Patients with Inflammatory Bowel Disease.

Background: Biologics are a cornerstone in the treatment of severe cases of inflammatory bowel disease (IBD) and aim to control the disease and improve quality of life. This study investigated changes in nonbiologic medication prescriptions for IBD patients initiating biologic therapy in Germany. Methods: This study used data from anonymized pharmacy records in the German longitudinal prescription (LRx) database and included biologic-naive IBD patients who received their first biologic therapy prescription between 2016 and 2022. Changes in prescription rates and pill counts for nonbiologic medications (corticosteroids, 5-aminosalicylates (5-ASA), proton pump inhibitors, analgesics, immunosuppressants, Vitamin D, iron, and antibiotics) before and after the initiation of biologic therapy were assessed using descriptive statistics, McNemar's tests, and Poisson regression models, adjusting for age and sex. Results: A total of 29,559 biologic-naive IBD patients were included. Prior to index, 91.2% received at least one nonbiologic medication prescription, where corticosteroids and 5-ASA were the most common. Postindex, the overall prescription rate decreased to 87.7%, with significant reductions in prescriptions observed for corticosteroids, 5-ASA, and immunosuppressants (p-values < 0.001). The mean (SD) pill count dropped from 704 (1712) to 514 (1651), with the largest mean differences (95% CI) having been for corticosteroids (-77.9 [-80.3 to -75.5]), 5-ASA (-61.6 [-65.2 to -58.1]), and immunosuppressants (-55.0 [-57.5 to -52.6]). Older patients tended to have greater decreases in pill counts for corticosteroids and 5-ASA, while males showed statistically significant reductions in pill count for immunosuppressants compared with females. Conclusions: This study demonstrates that the prescription of nonbiologic medications significantly decreased after biologic therapy initiation. The use of biologics may therefore lead to improved disease management and potentially better patient outcomes.

Determinants of immune checkpoint inhibitor use and factors linked to neurological adverse events in Korean lung cancer.

Aim: Studies on immune checkpoint inhibitor (ICI)-related potential neurological adverse events (pNAEs) in Korean lung cancer (LC) patients are scarce. We aimed to examine ICI prescription trends from 2018 to 2022, patient characteristics and factors associated with ICI prescription or concurrent pNAEs in LC.Research design & methods: This observational, cross-sectional study of Korean LC patients investigated four ICIs (pembrolizumab, nivolumab, atezolizumab and durvalumab). The annual ICI prescription rate was calculated by dividing the number of LC patients prescribed ICIs with the total annual number of LC patients. Factors associated with ICI prescriptions or concurrent pNAEs were assessed.Results: The annual ICI prescription rate increased from 3.29% to 9.74% (average: 6.20%). Higher Charlson Comorbidity Index (CCI) scores were associated with more ICI prescriptions (odds ratio [OR], 1.08; 95% confidence interval [CI], 1.07-1.08). Targeted therapy was associated with fewer prescriptions (OR: 0.45; 95% CI: 0.41-0.49). The anti-programmed cell death protein 1 (anti-PD-1) prescription rate was higher in patients with concurrent pNAEs than those without pNAEs (53.09% vs. 50.84%), and this was associated with higher pNAEs prevalence (OR: 1.10; 95% CI: 1.03-1.18).Conclusion: ICI prescription for LC has increased in Korea, CCI and anti-PD-1 increased pNAEs prevalence.

Accelerating adverse pregnancy outcomes research amidst rising medication use: parallel retrospective cohort analyses for signal prioritization

BackgroundPregnant women are significantly underrepresented in clinical trials, yet most of them take medication during pregnancy despite the limited safety data. The objective of this study was to characterize medication use during pregnancy and apply propensity score matching method at scale on patient records to accelerate and prioritize the drug effect signal detection associated with the risk of preterm birth and other adverse pregnancy outcomes.MethodsThis was a retrospective study on continuously enrolled women who delivered live births between 2013/01/01 and 2022/12/31 (n = 365,075) at Providence St. Joseph Health. Our exposures of interest were all outpatient medications prescribed during pregnancy. We limited our analyses to medication that met the minimal sample size (n = 600). The primary outcome of interest was preterm birth. Secondary outcomes of interest were small for gestational age and low birth weight. We used propensity score matching at scale to evaluate the risk of these adverse pregnancy outcomes associated with drug exposure after adjusting for demographics, pregnancy characteristics, and comorbidities.ResultsThe total medication prescription rate increased from 58.5 to 75.3% (P < 0.0001) from 2013 to 2022. The prevalence rate of preterm birth was 7.7%. One hundred seventy-five out of 1329 prenatally prescribed outpatient medications met the minimum sample size. We identified 58 medications statistically significantly associated with the risk of preterm birth (P ≤ 0.1; decreased: 12, increased: 46).ConclusionsMost pregnant women are prescribed medication during pregnancy. This highlights the need to utilize existing real-world data to enhance our knowledge of the safety of medications in pregnancy. We narrowed down from 1329 to 58 medications that showed statistically significant association with the risk of preterm birth even after addressing numerous covariates through propensity score matching. This data-driven approach demonstrated that multiple testable hypotheses in pregnancy pharmacology can be prioritized at scale and lays the foundation for application in other pregnancy outcomes.