Subsequent Prescribing Research Articles

Parental self-medication with antibiotics for children promotes antibiotic over-prescribing in clinical settings in China

BackgroundSelf-medication with antibiotics (SMA) is one of the most dangerous inappropriate antibiotic use behaviors. This study aims to investigate the impact of parental SMA for children before a consultation on their doctor’s subsequent antibiotic prescribing behavior, including intravenous (IV) antibiotic use in the clinical setting of China.MethodsA cross-sectional survey was conducted between June 2017 and April 2018 in three provinces of China. A total of 9526 parents with children aged 0–13 years were investigated. Data from 1275 parents who had self-medicated their children and then visited a doctor in the past month were extracted and analyzed.ResultsOne-third (410) of the studied children had parental SMA before the consultation and 83.9% of them were subsequently prescribed antibiotics by doctors. Children with parental SMA were more likely to be prescribed antibiotics (aOR = 7.79, 95% CI [5.74–10.58]), including IV antibiotics (aOR = 3.05, 95% CI [2.27–4.11]), and both oral and IV antibiotics (aOR = 3.42, 95% CI [2.42–4.84]), than children without parental SMA. Parents with SMA behaviors were more likely to request antibiotics (aOR = 4.05, 95% CI [2.59–6.31]) including IV antibiotics (aOR = 2.58, 95% CI [1.40–4.76]), and be fulfilled by doctors (aOR = 3.22, 95% CI [1.20–8.63]).ConclusionsTailored health education for parents is required in both community and clinical settings to discourage parental SMA for children. The doctors should not prescribe unnecessary antibiotics to reinforce parents’ SMA behaviors. We recommend expanding the current IV antibiotics ban in outpatient settings of China to cover outpatient pediatrics.

Practice change intentions after academic detailing align with subsequent opioid prescribing

ObjectiveSelf-reported behavior change is used to evaluate the effectiveness of educational outreach interventions delivered to clinicians, such as academic detailing (AD). However, self-reported changes in behavior are often not corroborated with data on actual behavior change. To assess alignment between self-reported practice change intentions and actual opioid prescribing behavior among primary care clinicians after an AD intervention. MethodsWe used a difference-in-differences approach to compare pre-post changes in opioid prescribing using data from the Illinois Prescription Monitoring Program. An opioid-focused AD intervention was delivered to primary care clinicians from a large health system in the Chicago metropolitan area from June 2018 to August 2018. Immediately after the AD intervention, clinicians were administered a single-item self-reported practice change measure. Clinicians were categorized into 2 groups on the basis of their responses: (1) intention to change and (2) no-to-moderate intention to change. Outcomes were mean total opioid prescriptions and high-dose opioid prescriptions (≥ 90 morphine milligram equivalents) per clinician per month. Repeated measures linear regression models were used to compare changes in opioid prescribing outcomes between the 2 groups in the 6 months before and after the AD intervention. ResultsA total of 149 clinicians were included for analysis. An intention to change was reported by 72 clinicians and no-to-moderate intention to change was reported by 77 clinicians. In the 6 months after the AD intervention, there were 1.48 (95% CI −2.48 to −0.47) fewer total opioid prescriptions and 0.50 (−0.69 to −0.31) fewer high-dose opioid prescriptions per clinician per month in the intention to change group than in the no-to-moderate intention to change group. ConclusionThis study showed considerable alignment between self-reported practice change intentions and actual changes in opioid prescribing behavior. Future opioid-focused educational outreach interventions should consider using standardized single-item practice change measures as an immediate indicator of future behavior change.

Antibiotic Prescribing to Patients with Infectious and Non-Infectious Indications Admitted to Obstetrics and Gynaecology Departments in Two Tertiary Care Hospitals in Central India.

Background: Patients admitted to obstetrics and gynaecology (OBGY) departments are at high risk of infections and subsequent antibiotic prescribing, which may contribute to antibiotic resistance (ABR). Although antibiotic surveillance is one of the cornerstones to combat ABR, it is rarely performed in low- and middle-income countries. Aim: To describe and compare antibiotic prescription patterns among the inpatients in OBGY departments of two tertiary care hospitals, one teaching (TH) and one nonteaching (NTH), in Central India. Methods: Data on patients’ demographics, diagnoses and prescribed antibiotics were collected prospectively for three years. Patients were divided into two categories- infectious and non-infectious diagnosis and were further divided into three groups: surgical, nonsurgical and possible-surgical indications. The data was coded based on the Anatomical Therapeutic Chemical classification system, and the International Classification of Disease system version-10 and Defined Daily Doses (DDDs) were calculated per 1000 patients. Results: In total, 5558 patients were included in the study, of those, 81% in the TH and 85% in the NTH received antibiotics (p < 0.001). Antibiotics were prescribed frequently to the inpatients in the nonsurgical group without any documented bacterial infection (TH-71%; NTH-75%). Prescribing of broad-spectrum, fixed-dose combinations (FDCs) of antibiotics was more common in both categories in the NTH than in the TH. Overall, higher DDD/1000 patients were prescribed in the TH in both categories. Conclusions: Antibiotics were frequently prescribed to the patients with no documented infectious indications. Misprescribing of the broad-spectrum FDCs of antibiotics and unindicated prescribing of antibiotics point towards threat of ABR and needs urgent action. Antibiotics prescribed to the inpatients having nonbacterial infection indications is another point of concern that requires action. Investigation of underlying reasons for prescribing antibiotics for unindicated diagnoses and the development and implementation of antibiotic stewardship programs are recommended measures to improve antibiotic prescribing practice.

Validation of the Drip Score at A Community-Teaching Hospital

Rationale Recent data suggest that health care–associated pneumonia (HCAP) criteria has poor predictive value in determining risk for drug-resistant pathogens (DRPs) and leads to increased use of broad-spectrum antibiotics. The Drug Resistance in Pneumonia (DRIP) Score highlights a selective set of criteria to predict pneumonia risk. Validation studies show conflicting results on the impact of antibiotic selection based on the DRIP score. Methods This was a retrospective chart review of hospitalized patients from March 2018 to April 2018 who were started on antibiotics for a respiratory tract infection. The HCAP criteria and DRIP scores were calculated and antibiotic selection was analyzed. The primary focus was to determine if utilization of the DRIP score could modify antipseudomonal beta-lactam (APBL) prescribing patterns. Results A total of 82 patients were included in the study. Sixty-four (78%) patients had a DRIP score &lt;4 with 19 (30%) receiving an APBL. There were 18 patients with a DRIP score &gt;4, and 7 (39%) patients received non-APBL antibiotics. The HCAP criteria and subsequent prescribing was also analyzed. Forty-nine patients were identified as not meeting HCAP criteria. Of these patients, 12 (24%) received APBL. Thirty-three patients met HCAP criteria, and 15 (45%) received a non-APBL. If HCAP criteria were used to guide antibiotic prescribing, we would see a net increase of 3% in APBL use; whereas if DRIP scores were implemented, we would see a net decrease of 14% in APBL use. Conclusions Our study indicates that implementation of the DRIP score would result in decreased empiric APBL use.

119-LB: Metformin Prescriptions in Chronic Kidney Disease Patients after the Revised FDA Recommendations in 2016

Background: In 2016, metformin’s prescribing label was revised to permit it to be started with estimated glomerular filtration rate (eGFR) 45-60 ml/min and continued with eGFR 30-44 ml/min. We examined whether subsequent metformin prescribing in these groups increased. Methods: We conducted an interrupted time series study using data from the New York City Clinical Data Research Network. We identified episodes from 2014-2017 in which adult patients with HbA1c ≥6.5% received outpatient antidiabetic prescriptions ≤7 days after an eGFR measurement. Trends in the proportion of episodes that included metformin were examined using linear regression in 4 eGFR subgroups: ≥60 (reference), 45-59, 30-44, and &amp;lt;30 ml/min. Sensitivity analysis examined episodes with no antidiabetic prescription in the prior 180 days. Results: We identified 10,608 prescribing episodes among 6,505 patients. Lower eGFR was associated with less metformin prescribing. In the eGFR 30-44 ml/min group, there were significant increases in metformin prescribing after the label change (p&amp;lt;0.001). In sensitivity analysis, an increasing trend in metformin prescriptions in the 45-59 ml/min eGFR group started before the label change (p=0.04) and leveled off. Conclusion: Metformin prescribing for patients with eGFR 30-60 ml/min was increasing prior to the label change. Rates of metformin use at eGFR 30-45 ml/min remain relatively low. Disclosure J. Min: None. X. Wu: None. J. Orloff: None. A.I. Mushlin: None. J. Flory: None. Funding Patient-Centered Outcomes Research Institute (CER-9230)

Lack of improvement in antimicrobial prescribing after a diagnosis of Clostridium difficile and impact on recurrence

Antimicrobial use is one of the largest modifiable risk factors for development of Clostridium difficile infection (CDI). We sought to determine if a recent diagnosis of CDI affected the appropriateness of subsequent antimicrobial prescribing. This study is a retrospective electronic chart review of the Greater Los Angeles Veterans Administration. Medication administration records were reviewed for all patients with new CDI from 2015-2016 to determine the appropriateness (drug choice, duration, and dosage) of all non-CDI antimicrobials prescribed within 90 days pre- and post-initial CDI (iCDI) positive testing. Of the 210 patients diagnosed with new-onset iCDI, 140 met inclusion criteria. Of antimicrobial courses prescribed, 40.6% of pre-iCDI were inappropriate compared with 43.1% of post-iCDI, demonstrating no difference in prescribing habits (P = .717). Thirty-three patients developed recurrent CDI (rCDI). After adjustment for other known risk factors, inappropriate antimicrobial use was associated with a significant increased risk of recurrence compared with appropriate use alone (odds ratio [OR], 6.19; 95% confidence interval [CI], 1.45-26.42). Antimicrobial use in general was associated with increased recurrence compared with no antimicrobial use post-iCDI (OR, 2.6; 95% CI, 1.16-5.84); however, after adjustment, it was no longer significant (OR, 2.13; 95% CI, 0.90-5.04). The appropriateness of antimicrobial prescribing was not affected by the diagnosis of recent CDI. Inappropriate antimicrobial use after iCDI was associated with higher risk of rCDI.

Association of Pharmaceutical Industry Marketing of Opioid Products to Physicians With Subsequent Opioid Prescribing

This database analysis examines the extent to which pharmaceutical industry marketing of opioid products to physicians during 2014 was associated with opioid prescribing during 2015.

Impact of safety warnings on domperidone prescribing in Ireland.

This study aimed to investigate the impact of the 2014 safety warnings on use of domperidone, on subsequent prescribing patterns in Ireland. The Irish HSE-PCRS pharmacy claims database was used to identify the study cohort (aged 18+), prescribed domperidone from Jan 2014 to Oct 2015. Dosage was available for each claim; concomitant prescription with the following drug classes was identified and calculated as a percentage of the total number of claims: anti-arrhythmics, macrolide antimicrobials and the selective serotonin receptor inhibitors (SSRIs) citalopram and escitalopram. Segmented regression analysis was used to examine the changes in prescribing before and after the issue of safety warnings in May 2014. A total of 397,572 claims for domperidone were identified from Jan 2014 to Oct 2015. Overall, there was a significant decline in numbers receiving domperidone during the study period (from 22,226 to 15,691 claims, p=0.012), with no significant change over time. In addition, no significant change in co-prescribed SSRIs or anti-arrhythmic agents was observed over time; co-prescribed macrolide antimicrobials significantly increased after the safety advisory compared to trends before (p=0.031). In those aged 60+years, 10% of claims (n=1332) were for doses >30mg/day at the start of the study with no significant change in dose after the May advisory. Safety warnings concerning domperidone appeared to have had little effect on prescribing patterns in Ireland. Of concern is the continuing co-prescription with drugs known to increase the risk of QT prolongation, in all ages, including the 60+ year age group.

Constitutional Symptoms Trigger Diagnostic Testing Before Antibiotic Prescribing in High-Risk Nursing Home Residents.

To evaluate the use of diagnostic testing before treating an infection in nursing home (NH) residents suspected of having a urinary tract infection (UTI) or pneumonia. Prospective longitudinal study nested within a randomized trial, using data from control sites. Six NHs in southeast Michigan. NH residents with an indwelling urinary catheter, enteral feeding tube, or both (N = 162) with 695 follow-up visits (189 (28%) visits with an infection). Clinical and demographic data-including information on incident infections, antibiotic use, and results of diagnostic tests-were obtained at study enrollment, after 14 days, and monthly thereafter for up to 1 year. One hundred (62%) NH residents had an incident infection requiring antibiotics, with substantial variations between NHs. In addition to presence of infection-specific symptoms, change in function was a significant predictor of ordering a chest X-ray to detect pneumonia (odds ratio (OR) = 1.7, P = .01). Similarly, change in mentation was a significant predictor of ordering a urinalysis (OR = 1.9, P = .02), chest X-ray (OR = 3.3, P < .001), and blood culture (OR = 2.3, P = .02). Antibiotics were used empirically, before laboratory results were available, in 50 of 233 suspected cases of UTI (21.5%) and 16 of 53 (30.2%) suspected cases of pneumonia. Antibiotics were used in 17% of visits without documented clinical or laboratory evidence of infection. Constitutional symptoms such as change in function and mentation commonly lead to diagnostic testing and subsequent antibiotic prescribing. Antibiotic use often continues despite negative test results and should be a target for future interventions.

Understanding flucloxacillin prescribing trends and treatment non-response in UK primary care: a Clinical Practice Research Datalink (CPRD) study.

ObjectivesThe volume of prescribed antibiotics is associated with antimicrobial resistance and, unlike most other antibiotic classes, flucloxacillin prescribing has increased. We aimed to describe UK primary care flucloxacillin prescribing and factors associated with subsequent antibiotic prescribing as a proxy for non-response.Patients and methodsClinical Practice Research Datalink patients with acute prescriptions for oral flucloxacillin between January 2004 and December 2013, prescription details, associated Read codes and patient demographics were identified. Monthly prescribing rates were plotted and logistic regression identified factors associated with having a subsequent antibiotic prescription within 28 days.Results3 031 179 acute prescriptions for 1 667 431 patients were included. Average monthly prescription rates increased from 4.74 prescriptions per 1000 patient-months in 2004 to 5.74 (increase of 21.1%) in 2013. The highest prescribing rates and the largest increases in rates were seen in older adults (70+ years), but the overall increase in prescribing was not accounted for by an ageing population. Prescribing 500 mg tablets/capsules rather than 250 mg became more common. Children were frequently prescribed low doses and small volumes (5 day course) and prescribing declined for children, including for impetigo. Only 4.2% of new prescriptions involved co-prescription of another antibiotic. Age (<5 and ≥60 years), diagnosis of ‘cellulitis or abscess’ or no associated code, and 500 mg dose were associated with a subsequent antibiotic prescription, which occurred after 17.6% of first prescriptions.ConclusionsThere is a need to understand better the reasons for increased prescribing of flucloxacillin in primary care, optimal dosing (and the need to co-prescribe other antibiotics) and the reasons why one in five patients are prescribed a further antibiotic within 4 weeks.

22 Retrospective Regional Audit of In-Patient Assessment of Left Ventricular Systolic Function and Guideline-Recommended Prescription of Eplerenone following St-elevation Myocardial Infarction

Introduction The Eplerenone Post-Acute Myocardial Infarction Heart Failure Efficacy and Survival Study (EPHESUS) trial demonstrated that eplerenone reduces all-cause mortality and death or hospitalisation for cardiovascular events in patients with symptomatic left ventricular (LV) systolic dysfunction (ejection fraction ≤40%) or diabetes following ST-elevation myocardial infarction (STEMI). Current national and international guidelines recommend initiation of eplerenone in this patient group. We conducted a retrospective audit of assessment of LV systolic function and subsequent prescribing of eplerenone in eligible patients presenting with acute STEMI over a 4-month period. Aims and objectives 1. Establish what proportion of patients presenting with STEMI had in-patient assessment of LV systolic function 2. Identify whether LV systolic function assessment was performed qualitatively or quantitatively 3. Determine what proportion of eligible patients were prescribed eplerenone on hospital discharge Methods Patients from NHS Greater Glasgow and Clyde (GG&C) who underwent primary percutaneous coronary intervention (PPCI) for STEMI were retrospectively (01/08/13–30/11/13) identified using the coronary intervention patient-database at the West of Scotland Regional Heart and Lung Centre (Golden Jubilee National Hospital). Data were collected using electronic patient records and national radiology archive. Qualitative assessment was defined as a subjective description of LV systolic function (normal, mild, moderate or severe impairment). Quantitative assessment was defined as a documented ejection fraction (EF). Patients were considered eligible for eplerenone if they had a qualitative assessment of LV systolic function documented as moderately or severely impaired, or EF ≤ 40% on quantitative assessment, and symptomatic LV systolic dysfunction or diabetes. Results 172 patients were identified. 90% of the total population had in-patient assessment of LV systolic function ([Table 1][1]). All of these patients had qualitative assessment ([Table 1][1]). LV systolic function was quantitatively assessed in 27% (10% modified Simpson’s Biplane method, 11% estimated EF, 5% unspecified) ([Table 1][1]). 8% of patients were considered eligible for eplerenone ([Table 2][2]). Of those eligible, eplerenone was appropriately prescribed on discharge in 21% ([Table 2][2]). View this table: Abstract 22 Table 1 Assessment of LV systolic function View this table: Abstract 22 Table 2 Prescribing of eplerenone in eligible patients Conclusions This audit indicates that national and international guidelines for the assessment and management of LV systolic function post-STEMI are not being adhered to within this region. Identifying those with LV systolic dysfunction post-STEMI is not only of importance for the optimisation of drug therapy, but also for patient selection for implantable defibrillators. The wider implications of LV systolic dysfunction include DVLA-imposed restrictions on driving and critical illness policies. Potential barriers to compliance with guidelines include time-constraints, training and shorter inpatient stay since the adoption of PPCI. These factors may explain the low prescribing rate of eplerenone in eligible patients. [1]: #T1 [2]: #T2

Initial therapy, persistence and regimen change in a cohort of newly treated type 2 diabetes patients.

The aim was to describe the utilization of antidiabetic agents, in terms of persistence and regimen change, in the management of a cohort of newly treated type 2 diabetes patients and to investigate associated socio-demographic and treatment factors. A population-based retrospective cohort study was conducted using the national pharmacy claims database in Ireland. Subjects were analyzed for persistence and regimen change. Cox proportional hazards regression examined associations of socio-demographic and treatment factors on treatment patterns. Hazard ratios (HR) and 95% CIs are presented. A total of 20947 subjects were identified in the study over a 2 year period. Most were initiated on metformin (76%) or sulphonylureas (22%) and 77% were persistent with therapy 12 months after initiation. The likelihood of non-persistence was significantly lower in the youngest (40-49 years) age groups (reference 60-69 years) (HR 1.62, 95% CI 1.42, 1.84) and those on sulphonylureas (HR 1.49, 95% CI 1.36, 1.64). The likelihood of receiving a regimen change was significantly lower in the older (80+ years) age groups (HR 0.63, 95% CI 0.56, 0.71), females (HR 0.91, 95% CI 0.86, 0.95), and those with pre-existing CVD (1 vs. 0 CVD medicines) (HR 0.82, 95% CI 0.74, 0.90), and higher in those on sulphonylureas (HR 1.83, 95% CI 1.73, 1.94). Type of treatment, pre-existing CVD and demographic factors are shown to be associated with the observed treatment patterns. Guideline recommended agents were widely used on treatment initiation though a substantial minority were not initiated on the recommended first line agent. Use of guideline recommended agents was not as evident during treatment progression. Further optimization of initial and subsequent antidiabetic agent prescribing may be possible.

Can authorities appreciably enhance the prescribing of oral generic risperidone to conserve resources? Findings from across Europe and their implications.

BackgroundGeneric atypical antipsychotic drugs offer health authorities opportunities for considerable savings. However, schizophrenia and bipolar disorders are complex diseases that require tailored treatments. Consequently, generally there have been limited demand-side measures by health authorities to encourage the preferential prescribing of generics. This is unlike the situation with hypertension, hypercholaesterolaemia or acid-related stomach disorders.The objectives of this study were to compare the effect of the limited demand-side measures in Western European countries and regions on the subsequent prescribing of risperidone following generics; to utilise the findings to provide future guidance to health authorities; and where possible, to investigate the utilisation of generic versus originator risperidone and the prices for generic risperidone.MethodsPrincipally, this was a segmented regression analysis of retrospective time-series data of the effect of the various initiatives in Belgium, Ireland, Scotland and Sweden following the introduction of generic risperidone. The study included patients prescribed at least one atypical antipsychotic drug up to 20 months before and up to 20 months after generic risperidone. In addition, retrospective observational studies were carried out in Austria and Spain (Catalonia) from 2005 to 2011 as well as one English primary care organisation (Bury Primary Care Trust (PCT)).ResultsThere was a consistent steady reduction in risperidone as a percentage of total selected atypical antipsychotic utilisation following generics. A similar pattern was seen in Austria and Spain, with stable utilisation in one English PCT. However, there was considerable variation in the utilisation of generic risperidone, ranging from 98% of total risperidone in Scotland to only 14% in Ireland. Similarly, the price of generic risperidone varied considerably. In Scotland, generic risperidone was only 16% of pre-patent loss prices versus 72% in Ireland.ConclusionConsistent findings of no increased prescribing of risperidone post generics with limited specific demand-side measures suggests no ‘spillover’ effect from one class to another encouraging the preferential prescribing of generic atypical antipsychotic drugs. This is exacerbated by the complexity of the disease area and differences in the side-effects between treatments. There appeared to be no clinical issues with generic risperidone, and prices inversely reflected measures to enhance their utilisation.

The scottish model: Scottish medicines consortium (SMC)

UK health care is provided by a national health service (NHS), within which medicines are a major and growing cost. Concerns from patients, politicians, medical practitioners, and the press about “postcode” prescribing (marked regional differences in availability of newly licensed medicines) led to the creation of the Scottish Medicines Consortium (SMC). Run by NHS clinicians, SMC provides rapid advice on all new medicines, including new indications/formulations for existing therapies. A streamlined 2-stage pharmacy and health economic, and then strategic, review of submissions from industry by SMC provides an objective review of the data and a wider societal view of need. A patient perspective is included. Comparative cost-effectiveness is assessed, preferably by using QALY ICERs, and advice given close to UK licensing (usually within 4 months). This early advice means that physicians are prepared to wait for the decision from SMC, and prescribing is relatively uncommon outside the guidance. Three outcomes are possible: (1) accept for general use; (2) accept with restriction (by specialist prescriber, or only for a subgroup within the license); or (3) do not recommend for use in Scotland. Appeals can be heard and resubmissions can be made if the evidence base changes. Around 1000 submissions have now been made, including abbreviated submissions for minor license changes, since 2002. Around two thirds of all medicines were accepted for use in NHS Scotland but many in a way more restrictive than the license. Around 50% of resubmissions are accepted. Evidence suggests SMC decisions are not influenced by budget impact (affordability) but are strongly influenced by whether the drug provides value for money to the NHS in Scotland. Accepted modifiers of decisions include orphan indications, end-of-life treatment, bridging to a definitive treatment, and the development of licensed treatment where only an unlicensed preparation previously existed. Drug utilization data suggest that early advice influences prescribing patterns, in a positive way for approved drugs, and by lack of uptake (or reduction of existing prescribing) for those not recommended (with some exceptions). Benchmarking shows a high level of consistency with subsequent decisions from the National Institute for Health and Clinical Excellence (NICE), and the Pharmaceutical Benefits Advisory Committee (PBAC) in Australia. SMC has an ongoing horizon scanning program, created a Scottish Management of Antimicrobial Resistance action Plan (ScotMARAP; 2008), and now runs a Patient Access Scheme to make high-cost drugs affordable to Scottish patients. An open and inclusive process, involving key stakeholders, can produce useful, rigorous, evidence-based advice to a health care system in a way that is acceptable to the NHS and to the pharmaceutical industry, and occurs sufficiently early after the launch of a new drug to inform and influence subsequent prescribing patterns. None declared.

Physician Trainees’ Interactions with the Pharmaceutical Industry

The Authors’ Reply—The differences Ramachandran et al. note between our results1 and two other recent publications2,3 may be explained by both the analytic approaches used in our different studies and the outcomes we examined. In their important papers, both King et al. and Epstein et al. analyzed prescribing patterns for psychoactive drugs, using difference-in-differences models that dichotomized medical schools or residency training programs based on their conflict of interest policies alone, and found that those policies were important predictors of subsequent actual drug prescribing decisions. By contrast, we examined the relationship between students’ self-reported receipt of gifts and two characteristics of their medical schools—conflict of interest policies represented by the American Medical Student Association (AMSA) PharmFree Scorecard score and National Institutes of Health (NIH) funding. We found that students’ receipt of gifts correlates strongly with lower levels of NIH funding at their schools, but less so with the schools’ AMSA score after controlling for NIH funding level, suggesting that a higher AMSA score is closely correlated with a school’s receiving above-average NIH funding. As a result, the score may add little further power to account for this behavior beyond the research intensity of the institution. Our findings should not be interpreted to reduce the importance of institutional policies to control conflict of interest issues for trainees. This is still a young area of investigation, and more studies such as these are needed to clarify the best way to implement conflict of interest policies, and the effect of doing so on improving clinical decision-making. These policies emerged in the King et al. and Epstein et al. studies as valid predictors of subsequent rational prescribing behavior on the part of trainees. Despite these salutary downstream effects, our findings also suggest that the reported policies may not completely reflect the day-to-day reality of the medical learning environment that shape trainees. We agree with Ramachandran et al. that meaningful enforcement of conflict of interest policies is essential. Further research can identify better ways to measure implementation of these policies to ensure that resources are optimally directed to interventions that will change trainees’ attitudes and behaviors to benefit patients. Finally, we would like to direct readers’ attention to the revised Figure 1 in an accompanying Erratum. The original Figure contained clerical errors in the regression models.

Medical school gift restriction policies and physician prescribing of newly marketed psychotropic medications: difference-in-differences analysis

Objective To examine the effect of attending a medical school with an active policy on restricting gifts from representatives of pharmaceutical and device industries on subsequent prescribing behavior.Design Difference-in-differences approach.Setting...

Hypovitaminosis D in Psychiatric Inpatients: Clinical Correlation with Depressive Symptoms, Cognitive Impairment, and Prescribing Practices

The association of hypovitaminosis D with measures of depressive symptoms and cognitive impairment remains unclear. This correlation and subsequent prescribing practices of vitamin D supplementation were evaluated in a population of psychiatric inpatients. A retrospective study was conducted of 548 patients with a serum 25-hydroxyvitamin D [25(OH)D] level measured during hospitalization. Outcomes included the association of hypovitaminosis D with Patient Health Questionnaire (PHQ-9) and Folstein Mini-Mental State Exam (MMSE) scores, including an evaluation of vitamin D dosing upon hospital discharge. Two hundred three patients (37%) had hypovitaminosis D. The majority [183 (90%)] had moderate (10-24 ng/mL), while 20 (10%) had severe hypovitaminosis D (<10 ng/mL). There was no significant association between hypovitaminosis D and PHQ-9 or MMSE scores (p = 0.107 and p = 0.271, respectively). Overall, 33% of patients with moderate hypovitaminosis D and 45% of patients with severe hypovitaminosis D were newly prescribed vitamin D or received a dose increase. Initiation of vitamin D or increased vitamin D dose was significantly higher in patients with hypovitaminosis D (p < 0.001). No association was found between hypovitaminosis D and depressive symptoms or cognitive function. However, patients with hypovitaminosis D were more likely to be prescribed additional vitamin D at hospital discharge.

Physicians' motives for professional internet use and differences in attitudes toward the internet-informed patient, physician-patient communication, and prescribing behavior.

BackgroundPhysicians have differing motives for using the Internet and Internet-related services in their professional work. These motives may affect their evaluation of patients who bring with them health-related information from the Internet. Differing motives may also affect physician–patient communication and subsequent prescribing behavior.ObjectivesTo segment physicians into types based on their motives for using the Internet in connection with professional activities and to analyze how those segments differ in their attitudes in three areas: toward patients who bring along Internet-sourced information; in their own subsequent prescribing behavior; and in their attitudes toward using the Internet to communicate with patients in future.MethodsWe surveyed 287 German physicians online from three medical fields. To assess physicians’ motives for using the Internet for their professional activities, we asked them to rate their level of agreement with statements on a 7-point scale. Motive statements were reduced to motive dimensions using principal component analysis, and 2-step cluster analysis based on motive dimensions identified different segments of physicians. Several statements assessed agreement or disagreement on a 7-point scale physicians’ attitudes toward patients’ bringing Internet information to the consultation and their own subsequent prescribing behavior. Further, we asked physicians to indicate on a 7-point scale their valuation of the Internet for physician–patient communication in the future. Data were then subjected to variance and contingency analyses.ResultsWe identified three motive dimensions for Internet use: (1) being on the cutting edge and for self-expression (Cronbach alpha = .88), (2) efficiency and effectiveness (alpha = .79), and (3) diversity and convenience (alpha = .71). These three factors accounted for 71.4% of the variance. Based on physicians’ motives for using the Internet, four types of physician Internet user were identified: (1) the Internet Advocate (2), Efficiency-Oriented, (3) Internet Critic, and (4) Driven Self-expressionist. Groups differed significantly concerning (1) their attitude toward informed patients in general (F 1234 = 9.215, P < .001), (2) perceived improvement in the physician–patient relationship Internet information brings (F 1234 = 5.386, P < .001), (3) perceived accuracy of information the patient brings (F 1234 = 3.658, P = .01), and (4) perceived amount of time needed to devote to an Internet-informed patient (F 1234 = 3.356, P = .02). Physician segments did not differ significantly in reported prescribing behavior (F 1234 = 1.910, P = .13). However, attitudes toward using the Internet to communicate with patients in future differed significantly (F 1234 = 23.242, P < .001).ConclusionsBased on self-reporting by German physicians of their motives for professional Internet use, we identified four types of Internet users who differ significantly in their attitude toward patients who bring along Internet information and their attitudes toward using the Internet to communicate with patients in future.

A significant association was found between PPI* use and subsequent prescribing of bisphosphonates

A significant association was found between PPI* use and subsequent prescribing of bisphosphonates

Prescribing of anti‐osteoporotic therapies following the use of proton pump inhibitors in general practice

To determine the association, if any, between the prescribing of proton pump inhibitors and drugs for the management of osteoporosis. The study employed a retrospective cohort design using the Irish Health Services Executive (HSE) Primary Care Reimbursement Services (PCRS) pharmacy database, which contains prescription information for 1.2 million people (30% of the population). Those aged 55 years and over were included. Individuals were classified as new PPI users if they initiated PPI therapy after 2003, and those not receiving PPI therapy after 2003 as the comparison group. Subsequent prescribing of anti-osteoporotic therapy was considered from 2004 to 2007 in both groups. Adjusted odds ratios (OR and 95%CIs) were determined by logistic regression, adjusting for age, gender and medications, which potentially affect bone mineral density. 442,341 patients were identified, 209 175 were PPI users and the 233,166 were used as the comparison group. The odds ratio (95%CI) for the prescribing of anti-osteoporotic therapies following the prescribing of PPIs was OR = 1.69 (95%CI 1.66 1.72) compared to not receiving any PPI therapy, when adjusted for age and sex. When adjustments were made for other confounders, the OR decreased to OR = 1.26 (95%CI 1.23-1.28). The strength of the association increased with increasing duration of PPI therapy 6-12 months OR = 1.19 (95%CI 1.15-1.23) and for >24 months, OR= 2.09 (95%CI 2.04, 2.13) compared to < 3 months. The OR also increased with increase in dose of therapy. The results of the study indicate the association between the prescribing of bisphosphonates following the use of proton pump inhibitors may be clinically relevant.