Reasons For Inappropriate Use Research Articles

Are we using oxycodone appropriately? A utilisation review in a UK tertiary care centre

ObjectivesTo evaluate the utilisation of oxycodone in a tertiary care centre based in the North of England serving a population of 330 000.MethodsA prospective study which gathered data from October...

Impact of national transfusion indicators on appropriate blood usage in critically ill patients

The objective was to investigate the impact of three national blood transfusion indicators (NBTIs) specifically designed for critical care regarding the appropriate blood transfusion indications. This was a prospective, single-center study, carried out at a university hospital. A total of 1808 patients admitted to the intensive care unit (ICU) in 1 year were included. The study consisted of four 90-day periods (P). P1 was a control period with no intervention. P2 followed the inclusion of NBTIs into the ICU database, aimed at reinforcing NBTI knowledge. After presenting and discussing the results of P1 and P2, the early (P3) and late (P4) impacts of NBTI knowledge were evaluated. All patients who were transfused with at least 1 unit of any blood component (33.3%) were included. Thirteen percent of red blood cell transfusions (RBCTs) were given outside of NBTI protocols (13% deviation of NBTIs for RBCTs) without a significant change throughout the duration of the study. Most RBCTs (95%) were prescribed for a hemoglobin threshold of less than 90 g/L. There was a steady and significant improvement in the adherence to NBTI guidelines for platelet concentrate transfusions (PCTs) from 36% (P1) to 52% (P4; p < 0.01). In contrast, the lack of adherence to NBTI guidelines for fresh-frozen plasma transfusions (FFPTs) remained high (74%) and stable throughout the study period. The most frequent reason for inappropriate use of FFPTs or PCTs was absence of severe bleeding. The introduction of NBTI guidelines demonstrated a variable impact on the appropriateness of blood component transfusions in critically ill patients.

Uso prudente de antibióticos y propuestas de mejora desde la medicina hospitalaria

The largest consumption of antimicrobials is concentrated in hospitals and within them, the intensive care units. The quality of antimicrobial use is not optimal, with up to 50% of prescriptions being unnecessary or inappropriate. Inappropriate antibiotic use leads to severe consequences, such as increased patient mortality and morbidity and bacterial resistance. The primary reason for inappropriate use is the insufficient knowledge of the increasingly vast and complex information about the diagnosis and treatment of infectious diseases. There is general agreement on the need to improve the use of antimicrobials in hospitals but not on how to improve it. University Hospital Virgen del Rocío (Seville) has launched the Institutional Programme for the Optimisation of Antimicrobial Treatment (PRIOAM), inspired by the recommendations of the Infectious Diseases Society of America and adapted to the structural, functional and cultural characteristics of the hospital. PRIOAM is coordinated by a multidisciplinary team chosen by the Committee on Infections and Antimicrobials and has three basic characteristics: it is an institutional programme that has incentives linked to achieving goals; it is an educational programme in which training and knowledge are the basis for the proper use of antimicrobials; and it is a programme subject to results, in which the main objectives are clinical, not economic, to reduce mortality and morbidity in patients with infections and to delay the development of resistance.

Evaluation of Ceftriaxone Utilization at Multicenter Study

Background/AimsAs bacterial resistance to antimicrobial agents has grown due to the increasing use of antimicrobial agents, we sought to evaluate the suitability of ceftriaxone usage (representative of third generation cephalosporins) at 10 university hospitals in Korea.MethodsWe prospectively evaluated the appropriateness of antibiotic usage in 400 adult patients who received ceftriaxone between February 1, 2006 and June 30, 2006. Drug utilization evaluation (DUE) methods were based on standards set forth by the American Society of Hospital Pharmacists. The DUE criteria used in this study were modified to be more suitable in our hospital setting: justification of drug use, critical and process indications, complications, and outcome measures.ResultsThe average patient age was 64.4 years. The utilization of ceftriaxone was appropriate in 262 cases (65.5%) for the justification of use, while inappropriate use was observed in 138 cases (34.5%). Common reasons for inappropriate use of ceftriaxone included continued empiric use for presumed infections, prophylactic perioperative injection, and empiric therapy for fever. Most of the critical indications showed a high rate of suitability (66.5-98.5%). Complications occurred in 37 cases (9.3%). With respect to outcome measures, clinical responses were observed in 60.7% of cases, while only 15.7% of cases showed evidence of infection eradication via negative cultures.ConclusionsAppropriate use (65.5%) of ceftriaxone was higher than inappropriate use (34.5%) at university hospitals in Korea. Inappropriate utilization, however, including continued empiric use for presumed infections and prophylactic perioperative injection remained high. Intensification of educational programs and antibiotic control systems for ceftriaxone is needed to improve the suitability of antimicrobial use.

Patterns of ophthalmological complaints presenting to a dedicated ophthalmic Accident & Emergency department: inappropriate use and patients’ perspective

Objectives:To investigate the appropriateness of patients attending an Accident & Emergency (A&E) department of an eye hospital, identify reasons for inappropriate use and propose recommendations in improving the provision of...

Cumplimiento sobre las recomendaciones de uso y evaluación del impacto económico de un programa de uso restringido de imipenem-cilastatina

Imipenem is an expensive broad-spectrum antimicrobial, reserved for infections caused by multi-resistant nosocomial pathogens. Since 2001 our university hospital applies a restriction policy that allows rejecting or authorizing its use after a supervising evaluation with pre-specified criteria for appropriate or inappropriate use. An audit was performed for all the supervisions made during the periods of March-April and September-October, 2004, totalling 136 treatments. In global terms, 58.1% of treatments were considered appropriate and 11.8% inappropriate; other 20.6% had been discontinued by physicians in charge prior to evaluation. Susceptibility to other antimicrobials compounds was the main reason for inappropriate use. The remaining fraction involved deceased or discharged patients. Discontinuation of treatments by supervising physicians allowed to save 75 days and 362 vials of imipenem equivalent to US $ 6,777 during this period after discounting administrative and human resources costs.

Imipenem-cilastatin use in a university hospital in Chile

Imipenem is an expensive broad-spectrum antimicrobial, reserved for infections caused by multi-resistant nosocomial pathogens. Since 2001 our university hospital applies a restriction policy that allows rejecting or authorizing its use after a supervising evaluation with pre-specified criteria for appropriate or inappropriate use. An audit was performed for all the supervisions made during the periods of March-April and September-October, 2004, totalling 136 treatments. In global terms, 58.1% of treatments were considered appropriate and 11.8% inappropriate; other 20.6% had been discontinued by physicians in charge prior to evaluation. Susceptibility to other antimicrobials compounds was the main reason for inappropriate use. The remaining fraction involved deceased or discharged patients. Discontinuation of treatments by supervising physicians allowed to save 75 days and 362 vials of imipenem equivalent to US $ 6,777 during this period after discounting administrative and human resources costs.

Issues with prescribed medications in Aboriginal communities: Aboriginal Health Workers' perspectives

The health of Indigenous Australians remains appalling. The causes of this situation are multi-factorial, however one contributing factor is poor medication compliance within Aboriginal populations. Anecdotal evidence provided by Aboriginal health workers in western New South Wales (NSW), Australia, has suggested that there are problems associated with the use of prescribed medications within the Aboriginal community. Aboriginal health workers form a core component of the Aboriginal health service sector and they have an in-depth knowledge of the community and its healthcare provision, as well as a familiarity with clinic patients and families. As such they are an important group whose opinions and beliefs about medication use in the Aboriginal population should be investigated. While there have been studies on the issues of prescribing in Aboriginal communities and access to medications, limited investigation into the use of prescribed medicines in Aboriginal communities and the role of the pharmacist in that process, has taken place. Therefore, this research aimed to identify the type of and reasons for inappropriate use of prescribed medications within Aboriginal communities serviced by the Mid Western Area Health Service (since incorporated into the Greater West Area Health Service) as perceived by the Aboriginal health workers in the area, and to explore strategies in conjunction with those Aboriginal health workers to address identified issues. Qualitative, in-depth interviews were held with 11 Aboriginal health workers employed in Community Health Centres and hospitals in the Mid Western Area Health service of NSW. The interviews were audiotaped and transcribed verbatim. The transcripts were content analysed for emerging themes. The interviews explored the beliefs, perceptions and experiences of the Aboriginal health workers regarding prescribed medication use, the role of the pharmacist, and identification of future strategies to improve medication use in local Aboriginal communities. The Aboriginal health workers reported a general lack of access to medications and frequent inappropriate use of medications due to limited understanding, literacy and information all of which lead to non-compliance with instructions. Medication sharing was common in their communities. They reported that many Aboriginal people were uncomfortable seeking medicines advice, and the consumer medicine information provided was often difficult to understand, culturally inappropriate and unlikely to be utilised. Strategies suggested to improve pharmacist services and access to the services were a more 'Aboriginal friendly' environment, relationship development between pharmacists and Aboriginal health workers, cultural awareness programs for pharmacists and their staff, provision of disease state management services and medicine education programs by pharmacists for Aboriginal health workers. Medication misunderstandings and non-compliance within the Aboriginal community frequently occur. Suggestions to improve access, understanding and compliance, along with the education and training of Aboriginal health workers may provide tools for self-determination. Pharmacists may be well positioned to provide Aboriginal health workers with medicines information and patient education skills, and encourage the effective use of medicines within the Aboriginal community.

Inadequate Use of Acid-Suppressive Therapy in Hospitalized Patients and Its Implications for General Practice

Acid-suppressive therapy (AST) is largely prescribed in both hospital and general practice setting but few data are available on appropriateness of AST use in hospitalized patients and its fallout on prescribing in general practice. We assessed AST in patients consecutively admitted to an internal medicine department to determine the type and timing of prescription and indication for use according to widely accepted guidelines. Prescriptions were rated as indicated, acceptable, or not indicated. Overall, 58.7% of 834 admitted patients received AST, mainly proton pump inhibitors. The prescriptions were indicated in 50.1% of patients, not indicated in 41.5%, and acceptable in 6.5%. The main reason for inappropriate use was prophylaxis in low-risk patients (64.8%). On admission, 35.7% of 112 patients already on AST were judged to receive inappropriate prescription; of 348 patients discharged on AST, overuse was identified in 38.5%. No significant difference was observed for inappropriate use at admission, during hospitalization, and at discharge. In 64 inpatients (7.7%) AST, although indicated, mainly for ulcer prophylaxis in high-risk patients, was not prescribed. In conclusion, AST is substantially over-used in both hospital and general practice settings, mainly for ulcer prophylaxis in low-risk patients. On the other hand, AST is underused in a small, but not negligible proportion of high-risk patients.

Inappropriate use of an accident and emergency department: Magnitude, associated factors, and reasons—An approach with explicit criteria

Background: We evaluate the appropriateness of medical visits to the accident and emergency department (A&ED) of a university hospital using an instrument based on explicit and objective criteria, analyze the association between inappropriate visits and certain factors, and identify reasons for inappropriate use. Methods: This concurrent review of a random sample of 2,980 adult medical patients’ visits to the A&ED of the hospital of Elche uses the Hospital Urgencies Appropriateness Protocol, an instrument based on explicit criteria. We analyze the association between inappropriate use and specific factors, and provide a descriptive analysis of reasons for inappropriate use assigned by A&ED staff. Results: Of the total number, 882 (29.6%) of the visits were evaluated as inappropriate. Inappropriate use was associated with younger patients, use of own means of transportation, referral by the hospital, certain months of the year, and certain diagnostic groups of lesser severity. The most frequent reasons for inappropriate use were the patients’ greater trust in the hospital than primary care (451 [51.1%]), inappropriate use of services by patients (160 [18.1%]), and inappropriate referrals by primary care physicians (142 [16.1%]). Conclusion: Inappropriate use represents an important percentage of use of the A&ED. Many reasons contribute to it, although foremost among them is patient preference (and the convenience and accessibility) of these services compared with primary care. [Sempere-Selva T, Peiró S, Sendra-Pina P, Martínez-Espín C, López-Aguilera I. Inappropriate use of an accident and emergency department: magnitude, associated factors, and reasons—an approach with explicit criteria. Ann Emerg Med. June 2001;37:568-579.]

Appropriateness of ambulance transportation to a suburban pediatric emergency department

Objective. To assess the appropriateness of ambulance use in patients presenting to a pediatric emergency department (ED), with regard to both medical necessity and insurance status. Methods. The authors conducted a one-year retrospective chart analysis of all patients (age range 2 weeks to 19 years) who were transported via ambulance in 1994 to a suburban children's hospital ED. ED records of all patients who arrived by ambulance were abstracted for demographic data, type of insurance, chief complaint, medical interventions, discharge diagnosis, and disposition. Ambulance transportation was deemed unnecessary unless the medical record revealed any of the following criteria: 1) requiring cardiopulmonary resuscitation, 2) respiratory distress, 3) altered mental status or seizure, 4) immobilization, 5) inability to walk, 6) admission to intensive care, 7) ambulance recommended by medical personnel, 8) motor vehicle collision, or 9) parents not on scene. Results. 43% of the ambulance patients were insured by Medicaid, compared with 29% of the overall ED population. Thus, Medicaid patients were significantly more likely to use ambulance transportation than were patients with commercial insurance (p<0.001). 28% of patients who arrived by ambulance were judged to have used the ambulance transportation unnecessarily. Of the unnecessary transports, 60% were insured by Medicaid. Thus, Medicaid patients were significantly more likely to have used ambulance transportation unnecessarily (p<0.001). The most common reason for appropriate ambulance use was seizure activity; the most common reason for inappropriate use was fever. Conclusion. Inappropriate use of ambulance transportation is common in this pediatric population, with Medicaid patients accounting for a significant majority of the misuse.

Appropriateness and diagnostic yield of upper gastrointestinal endoscopy in an open-access endoscopy unit.

This prospective study tested the appropriateness of referrals for upper gastrointestinal endoscopy in an open-access endoscopy unit, using the criteria of the American Society for Gastrointestinal Endoscopy. It also examined whether there was any relationship between appropriateness of use and the presence of significant lesions detected by endoscopy. Four hundred fifty consecutive upper gastrointestinal endoscopies were studied prospectively. The referral indication was recorded by the endoscopist before the procedure was performed, and was compared with the current criteria of the American Society for Gastrointestinal Endoscopy and with endoscopic findings. The appropriateness of referral was assessed in 442 consecutive endoscopies. Of these, 252 (57%) were judged to be appropriate. In 168 (88%) of the 190 endoscopies rated as inappropriate, the reason was that the patient had not undergone empirical anti-ulcer therapy before endoscopy. The probability of finding a significant lesion did not differ between the endoscopies judged to be appropriate (50%) and those judged to be inappropriate (46%) Upper gastrointestinal endoscopy was frequently used for inappropriate indications. The main reason for inappropriate use was insufficient treatment, or no treatment, of dyspeptic symptoms prior to endoscopy. In this study, the criteria for appropriateness did not predict the probability of finding a significant endoscopic lesion.

Impact of therapeutic guidelines on antibiotic use by residents in primary care clinics.

Inappropriate use of antibiotics has been well documented for inpatient settings, but there are few studies in ambulatory patients. In a prospective study, the authors monitored the outpatient prescribing patterns of internal medicine residents and evaluated the effect of placing a one-page set of antibiotic guidelines in each patient examining room. Appropriateness of antibiotic choices was scored periodically. A 12-month pre-intervention survey of antibiotic use showed that 50% of the choices were inappropriate. Comparison of a four-month post-intervention analysis with the same four-month interval in the pre-intervention period showed no significant difference between the percentages of inappropriate prescriptions. The most common reasons for inappropriate use were: 1) failure to document a clinically significant bronchial infection, and 2) inadequate evaluation of nonspecific urinary tract complaints. The authors conclude that the ready availability of information about appropriate antibiotic use is not effective in changing antibiotic choices, and that educational strategies regarding antibiotic use must also address diagnostic evaluation.

Utilization of Pediatric Emergency Services: A Critical Review

The incidence of and reasons for inappropriate use of hospital emergency rooms are discussed. Among the approaches considered for decreasing non-emergency use of emergency rooms are educating the public as to proper use, redesigning emergency facilities to accommodate non-emergency patients, instituting hospital-based group practices, and educating health care providers as to the reasons patients seek emergency care.