Evaluation of the prescribing decision support system Synonyms in a primary care setting: a mixed-method study

BACKGROUND

Primary care prescribers must cope with an increasing number and complexity of considerations. Prescribing decision support systems (DSS) have therefore been developed to assist prescribers. Previous studies have shown that although there is wide variance in the different DSS available within primary care, barriers and facilitators to uptake remain. The Drug Synonyms function ('Synonyms') is a DSS inherent in the commercial electronic medical record system EMIS. Synonyms functionality has been further developed by the NHS Greater Glasgow and Clyde (GG&C) Central Prescribing Team to promote safe and cost-effective prescribing; however, it does not support the collection of usage data. As there is no knowledge on the uptake nor on the perceived effect of using Synonyms on prescribing, quantitative and qualitative analyses of Synonyms usage are required to ascertain the impact Synonyms has on primary care prescribers, which will influence the continued maintenance and/or future development of this prescribing DSS.

AIM

To determine the uptake of Synonyms and explore users' perceptions of its usefulness and future development.

DESIGN AND SETTING

An exploratory sequential mixed-method observational study using quantitative questionnaires, followed by semi-structured interviews with primary care prescribers within NHS GG&C.

METHOD

An electronic questionnaire (Questionnaire 1) accessible across 218 EMIS-compliant NHS GG&C GP practices ascertained Synonyms uptake by determining whether prescribers were aware of the DSS, whether they were aware of it and whether they used it. Prescribers who were aware of and used Synonyms were asked to opt in to participating further. This involved answering a second electronic questionnaire (Questionnaire 2), with the option of taking part in an additional one-to-one interview, to investigate their use and perceptions of Synonyms.

RESULTS

Questionnaire 1 was completed by 201 respondents from 43.1% of eligible GP practices: 186 (92.5%) respondents were aware of Synonyms, of whom 163 (87.6%) had used it and 155 (83.3%) continued to use it. Questionnaire 2 was completed by 104 respondents: 90 (86.5%) indicated that Synonyms informed or influenced their choice of drug prescribed; 94 (90.4%) reported that Synonyms changed their prescribing choice towards medication on NHS GG&C formulary, and 104 (100%) reported that they trust Synonyms. Six interviews generated suggestions for improvements, mainly extending the clinical conditions listed.

CONCLUSION

Most respondents were aware of and continued to use Synonyms. Respondents perceived Synonyms to influence prescribing choices towards local formulary medicines and improve adherence to local prescribing guidelines. Respondents trusted the DSS, but there is potential to increase awareness and training amongst non-users to encourage usage. Potentially, the NHS GG&C Synonyms function could be utilised by other health boards with supportive clinical systems.

GPs' understanding of the benefits and harms of treatments for long-term conditions: an online survey

Background

GPs prescribe multiple long-term treatments to their patients. For shared clinical decision-making, understanding of the absolute benefits and harms of individual treatments is needed. International evidence shows that doctors’ knowledge of treatment effects is poor but, to the authors knowledge, this has not been researched among GPs in the UK.

Aim

To measure the level and range of the quantitative understanding of the benefits and harms of treatments for common long-term conditions (LTCs) among GPs.

Design & setting

An online cross-sectional survey was distributed to GPs in the UK.

Method

Participants were asked to estimate the percentage absolute risk reduction or increase conferred by 13 interventions across 10 LTCs on 17 important outcomes. Responses were collated and presented in a novel graphic format to allow detailed visualisation of the findings. Descriptive statistical analysis was performed.

Results

A total of 443 responders were included in the analysis. Most demonstrated poor (and in some cases very poor) knowledge of the absolute benefits and harms of treatments. Overall, an average of 10.9% of responses were correct allowing for ±1% margin in absolute risk estimates and 23.3% allowing a ±3% margin. Eighty-seven point seven per cent of responses overestimated and 8.9% of responses underestimated treatment effects. There was no tendency to differentially overestimate benefits and underestimate harms. Sixty-four point eight per cent of GPs self-reported ‘low’ to ‘very low’ confidence in their knowledge.

Conclusion

GPs’ knowledge of the absolute benefits and harms of treatments is poor, with inaccuracies of a magnitude likely to meaningfully affect clinical decision-making and impede conversations with patients regarding treatment choices.

Evaluating the Concordance of Clinician Antiretroviral Prescribing Practices and HIV-ASSIST, an Online Clinical Decision Support Tool

BACKGROUND

Individualized selection of antiretroviral (ARV) therapy is complex, considering drug resistance, comorbidities, drug-drug interactions, and other factors. HIV-ASSIST (www.hivassist.com) is a free, online tool that provides ARV decision support. HIV-ASSIST synthesizes patient and virus-specific attributes to rank ARV combinations based upon a composite objective of achieving viral suppression and maximizing tolerability.

OBJECTIVE

To evaluate concordance of HIV-ASSIST recommendations with ARV selections of experienced HIV clinicians.

DESIGN

Retrospective cohort study.

PATIENTS

New and established patients at the Johns Hopkins Bartlett HIV Clinic and San Francisco Veterans Affairs HIV Clinic completing clinic visits were included. Chart reviews were conducted of the most recent clinic visit to generate HIV-ASSIST recommendations, which were compared to prescribed regimens.

MAIN MEASURES

For each provider-prescribed regimen, we assessed its corresponding HIV-ASSIST "weighted score" (scale of 0 to 10 +, scores of < 2.0 are preferred), rank within HIV-ASSIST's ordered listing of ARV regimens, and concordance with the top five HIV-ASSIST ranked outputs.

KEY RESULTS

Among 106 patients (16% female), 23 (22%) were ARV-naïve. HIV-ASSIST outputs for ARV-naïve patients were 100% concordant with prescribed regimens (median rank 1 [IQR 1-3], median weighted score 1.1 [IQR 1-1.2]). For 18 (17%) ARV-experienced patients with ongoing viremia, HIV-ASSIST outputs were 89% concordant with prescribed regimens (median rank 2 [IQR 1-3], median weighted score 1 [IQR 1-1.2]). For 65 (61.3%) patients that were suppressed on a current ARV regimen, HIV-ASSIST recommendations were concordant 88% of the time (median rank 1 [IQR 1-1], median weighted score 1.1 [IQR 1-1.6]). In 18% of cases, HIV-ASSIST weighted score suggested that the prescribed regimen would be considered "less preferred" (score > 2.0) than other available alternatives.

CONCLUSION

HIV-ASSIST is an educational decision support tool that provides ARV recommendations concordant with experienced HIV providers from two major academic centers for a diverse set of patient scenarios.

Cannabidiol prescription in clinical practice: an audit on the first 400 patients in New Zealand

Background

Cannabidiol (CBD) is the non-euphoriant component of cannabis. In 2017, the New Zealand Misuse of Drugs Regulations (1977) were amended, allowing doctors to prescribe CBD. Therapeutic benefit and tolerability of CBD remains unclear.

Aim

To review the changes in self-reported quality of life measurements, drug tolerability, and dose-dependent relationships in patients prescribed CBD oil for various conditions at a single institution.

Design & setting

An audit including all patients (n = 400) presenting to Cannabis Care, New Zealand, between 7 December 2017 and 7 December 2018 seeking CBD prescriptions

Method

Indications for CBD use were recorded at baseline. Outcomes included EuroQol quality of life measures at baseline and after 3 weeks of use, patient-reported satisfaction, incidence of side effects, and patient-titrated dosage levels of CBD.

Results

Four hundred patients were assessed for CBD and 397 received a prescription. Follow-up was completed on 253 patients (63.3%). Patients reported a mean increase of 13.6 points (P<0.001) on the EQ-VAS scale describing overall quality of health. Patients with non-cancer pain and mental-health symptoms achieved improvements to patient-reported pain and depression and anxiety symptoms (P<0.05). There were no major adverse effects. Positive side effects included improved sleep and appetite. No associations were found between CBD dose and patient-reported benefit.

Conclusion

There may be analgesic and anxiolytic benefits of CBD in patients with non-cancer chronic pain and mental health conditions such as anxiety. CBD is well tolerated, making it safe to trial for non-cancer chronic pain, mental health, neurological, and cancer symptoms.

The Persistence of Opioid Use Following Surgical Admission: An Australian Single-Site Retrospective Cohort Study

Background

Acute pain is common following surgery, with opioids frequently employed in its management. Studies indicate that commencing an opioid during a hospital admission increases the likelihood of long-term use. This study aimed to identify the prevalence of opioid persistence amongst opioid-naïve patients following surgery as well as the indication for use.

Methods

A retrospective review of patients who underwent a surgical procedure at the Royal Hobart Hospital, Tasmania, Australia, between August and September 2016 was undertaken. Patients were linked to the Tasmanian real-time prescription monitoring database to ascertain if they were subsequently dispensed a Schedule 8 opioid (morphine, codeine oxycodone, buprenorphine, hydromorphone, fentanyl, methadone, or tapentadol) and the indication for use.

Results

Of the 3275 hospital admissions, 1015 opioid-naïve patients were eligible for inclusion. Schedule 8 opioids were dispensed at or within 2 days of discharge in 41.7% of admissions. Thirty-nine (3.9%) patients received prescribed opioids 2-months post-discharge; 1.8% of the patients were approved by State Health to be prescribed Schedule 8 opioids regularly for a chronic condition at 6 months, and 1.3% received infrequent or one-off prescriptions for Schedule 8 opioids at 6 months. Thirteen (1.3%) patients continued Schedule 8 opioids for at least 6 months following their surgery, with the indication for treatment either related to the surgery or the condition which surgery was sought for.

Conclusion

This study found that there was a low rate of Schedule 8 opioid persistence following surgery, indicating post-surgical pain is not a significant driver for persistent opioid use.

Improving statin prescription through the involvement of nurses in the provision of ASCVD score: a quality improvement initiative in primary care

OBJECTIVES

This study compares two methods of providing CVD risk score on the percentage of appropriate statin therapy for primary prevention of CVD in family medicine clinics, according to the American Heart Association guidelines.

METHODS

Participants were non-diabetic patients aged 40 to 75 with a recently ordered low-density lipoprotein (LDL) level, not on statin therapy and free of CVD. The first intervention is passive with a display of the score on the EMR in the vital signs section and lasted for three months. The second intervention is collaborative where the nurses calculate the risk score and displayed it to the physician along with therapy recommendations. Electronic health records were reviewed to randomly select medical charts of eligible patients.

RESULTS

162 charts were randomly selected out of 547 eligible charts and included in the analysis, including 60 charts for the baseline group. Among moderate-risk patients, the percentage of appropriate statin initiation was 0% at baseline and after intervention 1; yet it increased to (33.3% [7.5-70.1, 95% CI]) after intervention 2. Among high risk patients, percentage of appropriate statin initiation was 9.1% [0.1-41.3, 95% CI], 11.1% [1.4, 34.7, 95% CI] and 28.6% [8.4, 58.1, 95% CI] during baseline, intervention 1 and intervention 2, respectively.

CONCLUSION

The provision of the CVD risk score alone as clinical decision support is not enough to improve statin initiation for primary prevention. The nurse collaboration can improve guideline-concordant statin initiation.

Trends in anticoagulant prescribing: a review of local policies in English primary care

Background

Oral anticoagulants are prescribed for stroke prophylaxis in patients with atrial fibrillation, which is the most common heart arrhythmia worldwide. The vitamin K antagonist (VKA) warfarin is a long-established anticoagulant. However, newer direct oral anticoagulants (DOACs) have been recently introduced as an alternative. Given the prevalence of atrial fibrillation, anticoagulant choice has substantial clinical and financial implications for healthcare systems. In this study, we explore trends and geographic variation in anticoagulant prescribing in English primary care. Because national guidelines in England do not specify a first-line anticoagulant, we investigate the association between local policies and prescribing data.

Methods

Primary care prescribing data of anticoagulants for all NHS practices from 2014 to 2019 in England was obtained from the ePACT2 database. Public formularies were accessed online to obtain local anticoagulation prescribing policies for 89.5% of clinical commissioning groups (CCGs). These were categorized according to their recommendations: no local policies, warfarin as first-line, or identification of a preferred DOAC (but not a preferred anticoagulant). Local policies were cross-tabulated with pooled prescribing data to measure the strength of association with Cramér’s V.

Results

Nationally, prescribing of DOACs increased from 9% of all anticoagulants in 2014 to 74% in 2019, while that of warfarin declined accordingly. Still, there was significant local variation. Across geographical regions, DOACs ranged from 53 to 99% of all anticoagulants. Most CCGs (73%) did not specify a first-line choice, and 16% recommended warfarin first line. Only 11% designated a preferred DOAC. Policies with a preferred DOAC indeed correlated with increased prescribing of that DOAC (Cramér’s V = 0.25, 0.27, 0.38 for rivaroxaban, apixaban, edoxaban respectively). However, local policies showed a negligible relationship with the classes of anticoagulants prescribed—DOAC or VKA (Cramér’s V = 0.01).

Conclusions

Nationally, the use of DOACs to treat atrial fibrillation has increased rapidly. Despite this, significant geographical variation in uptake remains. This study provides insights on how local policies relate to this variation. Our findings suggest that, in the absence of a nationally recommended first-line anticoagulant, local prescribing policies may aid in deciding between individual DOACs, but not in adjudicating between DOACs and vitamin K antagonists (i.e. warfarin) as general classes.

Development of a structured clinical pharmacology review for specialist support for management of complex polypharmacy in primary care

AIMS

Polypharmacy is widespread and associated with medication-related harms, including adverse drug reactions, medication errors and poor treatment adherence. General practitioners and pharmacists cite limited time and training to perform effective medication reviews for patients with complex polypharmacy, yet no specialist referral mechanism exists. To develop a structured framework for specialist review of primary care patients with complex polypharmacy.

METHODS

We developed the clinical pharmacology structured review (CPSR) and stopping by indication tool (SBIT). We tested these in an age-sex stratified sample of 100 people with polypharmacy aged 65-84 years from the Clinical Practice Research Datalink, an anonymised primary care database. Simulated medication reviews based on electronic records using the CPSR and SBIT were performed. We recommended medication changes or review to optimise treatment benefits, reduce risk of harm or reduce treatment burden.

RESULTS

Recommendations were made for all patients, for almost half (4.8 ± 2.4) of existing medicines (9.8 ± 3.1), most commonly stopping a drug (1.7 ± 1.3/patient) or reviewing with the patient (1.4 ± 1.2/patient). At least 1 new medicine (0.7 ± 0.9) was recommended for 51% patients. Recommendations predominantly aimed to reduce harm (44%). There was no relationship between number of recommendations made and time since last primary care medication review. We identified a core set of clinical information and investigations (polypharmacy workup) that could inform a standard screen prior to specialist review.

CONCLUSION

The CPSR, SBIT and polypharmacy workup could form the basis of a specialist review for patients with complex polypharmacy. Further research is needed to test this approach in patients in general practice.

Exploring the common prescribing errors that occur in the emergency department

BACKGROUND

Prescribing errors are a subset of medication errors that occur on the forms used to prescribe medicines for patients. On their discharge from the emergency department (ED), many patients are given a prescription form to obtain medicines from their local community pharmacist. On the identification of a prescribing error, the patient is sent back to the ED because the medicine cannot be dispensed.

AIM

To identify the most common prescribing errors on prescriptions returned to one large inner-city ED in South Wales from community pharmacies.

METHOD

Prescriptions that were returned to the ED over a six-week period from September and October 2016 were analysed to determine the types of prescribing errors that occurred and their frequency.

RESULTS

A total of 10,218 patients attended the ED over the six-week period, of which 7,731 patients were seen by a clinician and discharged home. Of these, 322 patients were discharged with a prescription, and 20 (6%) of these patients returned to the ED with a prescribing error that prevented the pharmacist from dispensing the medicines. The most common prescribing error was incorrect or missing prescriber information.

CONCLUSION

This study identified that there was a low rate of prescribing errors in the ED, and this was comparable with the rate of prescribing errors identified in the literature. Common prescribing errors could be mitigated through the introduction of electronic prescribing in the ED.

The impact of a Post-Take Ward Round Pharmacist on the Risk Score and Enactment of Medication-Related Recommendations

There is a scarcity of published research describing the impact of a pharmacist on the post-take ward round (PTWR) in addition to ward-based pharmacy services. The aim of this paper was to evaluate the impact of clinical pharmacists' participation on the PTWR on the risk assessment scores of medication-related recommendations with and without a pharmacist. This includes medication-related recommendations occurring on the PTWR and those recommendations made by the ward-based pharmacist on the inpatient ward. A pre-post intervention study was undertaken that compared the impact of adding a pharmacist to the PTWR compared with ward-based pharmacist services alone. A panel reviewed the risk of not acting on medication recommendations that was made on the PTWR and those recorded by the ward-based pharmacist. The relationship between the risk scores and the number and proportion of recommendations that led to action were compared between study groups. There were more medication-related recommendations on the PTWR in the intervention group when a pharmacist was present. Proportionately fewer were in the 'very high and extreme' risk category. Although there was no difference in the number of ward pharmacist recommendations between groups, there was a significantly higher proportion of ward pharmacist recommendations in the "very high and extreme" category in those patients who had been seen on a PTWR attended by a pharmacist than when a pharmacist was not present. There were a greater proportion of "low and medium" risk actionable medication recommendations actioned on the PTWR in the intervention group; and no difference in the risk scores in ward pharmacist recommendations actioned between groups. Overall, the proportion of recommendations that were actioned was higher for those made on the PTWR compared with the ward. The addition of a pharmacist to the PTWR resulted in an increase in low, medium, and high risk recommendations on the PTWR, more very high and extreme risk recommendations made by the ward-based pharmacist, plus an increased number of recommendations being actioned during the patients' admission.

Improving prescribing through big data approaches-Ten years of the Scottish Prescribing Information System

Medicines are a major component of modern healthcare delivery, both in resource consumption and as drivers of innovation. The ever-increasing application of digitalisation within day-to-day living and as part of our healthcare systems-with the resultant data generation-presents the opportunity to better define the populations exposed to medicines, and their benefits and harm in real world settings. This article outlines the development of the Scottish National Prescribing Information System (PIS) and describes how this capability is being used to support the safe and effective use of medicines, both nationally and internationally. Since 2009, PIS has included e-prescribed/e-dispensed and reimbursed medicines data, now totalling 976 million prescriptions, with codified structured data on dose instructions. A literature review, covering the period from January 2009 to March 2019, identified 40 full publications using PIS, the first occurring in 2014. The majority involved pharmacoepidemiology/drug-use studies (50%) in cancer and cardiovascular disease. Measuring the value and impact of PIS was extended beyond publication quantification by illustrating the translation of PIS outputs into the learning health system at scale. The developing Scottish capabilities add breadth and depth to the wider evolving international environment, and offer the potential to contribute collegiately to the global effort on medicine safety and effectiveness, including support for the World Health Organisation Global Patient Safety Challenge: Medication Without Harm.

Off-label Medications Use in the Eastern Province of Saudi Arabia: The Views of General Practitioners, Pediatricians, and Other Specialists

Background: Off-label drug prescribing remains a major pediatric health concern worldwide. The lack of studies in this vulnerable population causes many practitioners to prescribe drugs outside their license. This study aims to investigate and compare the current knowledge and views of general practitioners, pediatricians, and other specialists toward off-label pediatric prescribing. Methods: A descriptive, cross-sectional-based study conducted on a random sample of physicians who work in three different hospitals in the Eastern Province of Saudi Arabia. Results: Data were obtained from three hospitals, comprising a total of 160 practitioners. Overall, more than half of the participated practitioners (54%) were familiar with the definition of off-label prescribing. Thirty percentage of participated practitioners agreed that more than 10% of their prescribed medicines to children were off-labeled. A majority of participants expressed concerns over the efficacy (83%) and safety (92%) of off-label prescribing to children. Importantly, a noticeable proportion of the responders claimed that they sometimes observed an adverse drug reaction (n = 23; 20%) or treatment failure (n = 43; 37%) following off-label prescribing medicines to children. Only 46% participants have always informed the parents or guardian about the off-label prescription of medications to their children. Conclusion: A Large number of physicians are familiar with the concept of off-label prescribing of medicines to children in the Eastern Province of Saudi Arabia. Safety and efficacy are the main concerns of prescribing such medications. Policies toward improving pediatric clinical research and supporting the safety and efficacy of the drugs should be encouraged.

Multi-site evaluation of partnered pharmacist medication charting and in-hospital length of stay

AIMS

To undertake a multicentre evaluation of translation of a partnered pharmacist medication charting (PPMC) model in patients admitted to general medical units in public hospitals in the state of Victoria, Australia.

METHODS

Unblinded, prospective cohort study comparing patients before and after the intervention. Conducted in seven public hospitals in Victoria, Australia from 20 June 2016 to 30 June 2017. Patients admitted to general medical units were included in the study. Medication charting by pharmacists using a partnered pharmacist model was compared to traditional medication charting. The primary outcome variable was the length of inpatient hospital stay. Secondary outcome measures were medication errors detected within 24 h of the patients' admission, identified by an independent pharmacist assessor.

RESULTS

A total of 8648 patients were included in the study. Patients who had PPMC had reduced median length of inpatient hospital stay from 4.7 (interquartile range 2.8-8.2) days to 4.2 (interquartile range 2.3-7.5) days (P < 0.001). PPMC was associated with a reduction in the proportion of patients with at least 1 medication error from 66% to 3.6% with a number needed to treat to prevent 1 error of 1.6 (95% confidence interval: 1.57-1.64).

CONCLUSION

Expansion of the partnered pharmacist charting model across multiple organisations was effective and feasible and is recommended for adoption by health services.

Symptomatic Events in a Community Palliative Care Population: A Prospective Pilot Study

Background: The palliative care population is prescribed a large number of drugs, increasing as patients deteriorate. The cumulative effects of these medications combined with underlying symptom burden can result in significant morbidity. There is an urgent need to describe possible symptomatic events that could be exacerbated by commonly prescribed drugs in palliative care and their impact. Objectives: To trial the feasibility and acceptability of determining baseline symptomatic event rates for community palliative care patients from which a composite measure of symptomatic events can be developed. Design: This prospective pilot study of patient-reported symptomatic events recruited a convenience cohort of 27 community palliative care patients in a metropolitan specialist palliative care service in Australia. Results: This study has demonstrated a high prevalence rate of symptomatic events (total crude event/participant day rate 0.87) in the study population. Conclusion: Data collection of patient-centered symptomatic events was acceptable and feasible to participants. This pilot supports a fully powered study.

Adverse Outcomes of Polypharmacy in Older People: Systematic Review of Reviews

OBJECTIVE

Polypharmacy is widespread among older people, but the adverse outcomes associated with it are unclear. We aim to synthesize current evidence on the adverse health, social, medicines management, and health care utilization outcomes of polypharmacy in older people.

DESIGN

A systematic review, of systematic reviews and meta-analyses of observational studies, was conducted. Eleven bibliographic databases were searched from 1990 to February 2018. Quality was assessed using AMSTAR (A Measurement Tool to Assess Systematic Reviews).

SETTING AND PARTICIPANTS

Older people in any health care setting, residential setting, or country.

RESULTS

Twenty-six reviews reporting on 230 unique studies were included. Almost all reviews operationalized polypharmacy as medication count, and few examined medication classes or disease states within this. Evidence for an association between polypharmacy and many adverse outcomes, including adverse drug events and disability, was conflicting. The most consistent evidence was found for hospitalization and inappropriate prescribing. No research had explored polypharmacy in the very old (aged ≥85 years), or examined the potential social consequences associated with medication use, such as loneliness and isolation.

CONCLUSIONS AND IMPLICATIONS

The literature examining the adverse outcomes of polypharmacy in older people is complex, extensive, and conflicting. Until polypharmacy is operationalized in a more clinically relevant manner, the adverse outcomes associated with it will not be fully understood. Future studies should work toward this approach in the face of rising multimorbidity and population aging.

Regional analysis of UK primary care prescribing and adult service referrals for young people with attention-deficit hyperactivity disorder

BACKGROUND

Approximately 20% of children with attention-deficit hyperactivity disorder (ADHD) experience clinical levels of impairment into adulthood. In the UK, there is a sharp reduction in ADHD drug prescribing over the period of transition from child to adult services, which is higher than expected given estimates of ADHD persistence, and may be linked to difficulties in accessing adult services. Little is currently known about geographical variations in prescribing and how this may relate to service access.

AIMS

To analyse geographic variations in primary care prescribing of ADHD medications over the transition period (age 16-19 years) and adult mental health service (AMHS) referrals, and illustrate their relationship with UK adult ADHD service locations.

METHOD

Using a Clinical Practice Research Datalink cohort of people with an ADHD diagnosis aged 10-20 in 2005 (study period 2005-2013; n = 9390, 99% diagnosed <18 years), regional data on ADHD prescribing over the transition period and AMHS referrals, were mapped against adult ADHD services identified in a linked mapping study.

RESULTS

Differences were found by region in the mean age at cessation of ADHD prescribing, range 15.8-17.4 years (P<0.001), as well as in referral rates to AMHSs, range 4-21% (P<0.001). There was no obvious relationship between service provision and prescribing variation.

CONCLUSIONS

Clear regional differences were found in primary care prescribing over the transition period and in referrals to AMHSs. Taken together with service mapping, this suggests inequitable provision and is important information for those who commission and deliver services for adults with ADHD.

Impact of EMA regulatory label changes on systemic diclofenac initiation, discontinuation, and switching to other pain medicines in Scotland, England, Denmark, and The Netherlands

Purpose

In June 2013 a European Medicines Agency referral procedure concluded that diclofenac was associated with an elevated risk of acute cardiovascular events and contraindications, warnings, and changes to the product information were implemented across the European Union. This study measured the impact of the regulatory action on the prescribing of systemic diclofenac in Denmark, The Netherlands, England, and Scotland.

Methods

Quarterly time series analyses measuring diclofenac prescription initiation, discontinuation and switching to other systemic nonsteroidal anti‐inflammatory (NSAIDs), topical NSAIDs, paracetamol, opioids, and other chronic pain medication in those who discontinued diclofenac. Absolute effects were estimated using interrupted time series regression.

Results

Overall, diclofenac prescription initiations fell during the observation periods of all countries. Compared with Denmark where there appeared to be a more limited effect, the regulatory action was associated with significant immediate reductions in diclofenac initiation in The Netherlands (−0.42%, 95% CI, −0.66% to −0.18%), England (−0.09%, 95% CI, −0.11% to −0.08%), and Scotland (−0.67%, 95% CI, −0.79% to −0.55%); and falling trends in diclofenac initiation in the Netherlands (−0.03%, 95% CI, −0.06% to −0.01% per quarter) and Scotland (−0.04%, 95% CI, −0.05% to −0.02% per quarter). There was no significant impact on diclofenac discontinuation in any country. The regulatory action was associated with modest differences in switching to other pain medicines following diclofenac discontinuation.

Conclusions

The regulatory action was associated with significant reductions in overall diclofenac initiation which varied by country and type of exposure. There was no impact on discontinuation and variable impact on switching.

The impact of physicians' knowledge on outpatient antibiotic use: Evidence from China's county hospitals

We designed this study to explore how factors, especially knowledge, influence the use and prescriptions of antibiotics among physicians in China's county hospitals.A questionnaire was designed to evaluate the knowledge levels of physicians. The rates of antibiotic prescriptions were collected through on-the-spot investigations. The percentage of encounters with antibiotics prescribed and the percentage of encounters with antibiotics combination prescribed were used to measure antibiotics use. Univariate analysis and the generalized linear model were applied to analyze the knowledge levels among physicians as well as their antibiotic prescriptions.A total of 334 physicians in 60 county hospitals filled out the questionnaires, and 385,529 prescriptions were collected. The mean score of the questionnaire was a pass (62.8). The physicians in the eastern region of China demonstrated higher levels of knowledge than other regions (P = .08). Physicians with a higher score prescribed less antibiotics (P < .01) and less antibiotics combination (P = .07).The knowledge gap of Chinese physicians is evident and those with a higher degree of knowledge always prescribe fewer antibiotics. Targeted training and courses to educate physicians about the risks of over-prescription of antibiotics should be conducted to improve the practice of antibiotic prescriptions.

Levothyroxine prescriptions trends may indicate a downtrend in prescribing

BACKGROUND

There has been a trend for increased prescribing of levothyroxine (LT4) in many countries, including the United States. Several different factors have been suggested to be the cause of this practice pattern. These factors include increased size of the United States population, more diagnosis of hypothyroidism, more treatment of minimally elevated thyroid-stimulating hormone (TSH) levels, more use of LT4 in older patients, and use of LT4 for treatment of euthyroid patients with non-thyroidal conditions.

METHODS

The electronic databases of the MedStar Health system operating in the Washington, DC and Maryland areas were interrogated to determine the number of patients who were being prescribed levothyroxine during the time period 2008-2016, the number of prescriptions supplied to these individuals, the associated diagnosis, and whether the prescriptions were new or existing prescriptions. Regression analyses were also performed to determine the prescribing trends during this time period.

RESULTS

Although the annual number of levothyroxine prescriptions increased during this time period, the percentage of patients in the database receiving levothyroxine for hypothyroidism initially increased and then decreased over time (2.5% to 3.2% to 2.5%). The percentage of prescriptions written for patients who did not appear to carry a diagnosis of hypothyroidism steadily declined (3.5% to 1.0%). Although the percentage of patients with existing prescriptions for hypothyroidism initially increased and then were maintained at steady levels (1.4% to 2.4% to 2.2%), a smaller percentage of patients with existing prescriptions were documented over time when there was no diagnosis of hypothyroidism (1.45% to 0.89%). The percentage of patients with new prescriptions declined over time for all groups. The number of annual 90-day period prescriptions increased over the time for patients with a diagnosis of hypothyroidism, but down-trended starting over the latter part of the time period for those patients without a diagnosis of hypothyroidism.

CONCLUSION

Taken together, these data suggest that there may be a stabilization, and even a down-trend in levothyroxine prescribing with the MedStar system. The decrease in levothyroxine prescribing appears to be accounted for by less use of levothyroxine without an established diagnosis of hypothyroidism, and less initiation of new prescriptions.

Effectiveness of medication review on the number of drug-related problems in patients visiting the outpatient cardiology clinic: A randomized controlled trial

AIMS

To assess the effectiveness of medication review on the number of drug-related problems (DRPs) in outpatient cardiology patients.

METHODS

In this randomized controlled trial, a computer-assisted and pharmacist-led medication review with patient involvement (questionnaire and telephone call with pharmacist) was conducted in intervention patients prior to their visit to the cardiologist. The control group received usual care. Adult outpatient cardiology patients without support concerning the administration of medication, without a medication review in the past 6 months and who gave permission to access their electronic medication record were included. The primary outcome measure was the number of DRPs 1 month after the visit. Secondary outcome measures concerned the type of DRP and the type of medication involved in the DRPs.

RESULTS

In total, 75 patients (mean [standard deviation, SD] age 66.0 [12.5] years, 41% female) were included. Intervention (n = 90) and control group (n = 85) were comparable at baseline. The mean (SD) number of drugs used per patient was 7.9 (3.9). After 1 month, the mean (SD) number of DRPs was 0.3 (0.7) and 0.8 (1.0) and the median (range) number of DRPs was 0 (0-4) and 0 (0-4) in the intervention group and control group, respectively (P < .001). In the intervention group, 74% of the DRPs identified at T0 were solved at T1 vs 14% in the control group.

CONCLUSION

This randomized controlled trial suggests that a pharmacist-led medication review in patients with a scheduled visit to the outpatient cardiology clinic decreases the number of DRPs.

How do veterinarians influence sales of antimicrobials? A spatial-temporal analysis of the French prescribing-delivery complex in cattle

BACKGROUND

In animal agriculture, antimicrobials (AM) are used to control infectious diseases whose incidence and severity vary across production systems, but may contribute to select AM resistant bacteria, potentially disseminating in humans. Antimicrobial resistance (AMR) represents a public threat, leading policymakers to implement measures to reduce antimicrobial use (AMU). Investigating AMU patterns at prescriber's level, beyond national AMU trends, enables evaluation of substitutions between AM classes (occurring when one product is replaced by another), or average consumption per production system. Our aim was to identify the influence veterinarians would exert on AMU by quantifying substitution between AM products prescribed and delivered in similar therapeutic indications, in cattle production.

METHODS

Monthly sales data on four critically important AM in five French areas (representative of production systems) were analysed from 2008 to 2013. We calculated the animal live weight receiving a treatment course and evaluated substitutions between brand-name and generic products, and between products from different AM classes with similar indications.

RESULTS

Substitutions occurred, between products of the same class (macrolides) with similar indications, between generic and brand-name products (fluoroquinolones, ceftiofur, florfenicol) and between innovative and brand-name products (marbofloxacin, ceftiofur). Innovative products reaching the market represented between 2% and 40% of the yearly sales for a given molecule, depending on the active ingredient and the area. The introduction of generic products of fluoroquinolones and ceftiofur led to a moderate adoption of the generic product at the expense of the brand-name one, unlike in human health care where the adoption reaches up to 80%.

CONCLUSION

Veterinary prescription remains a strong regulating power of AMU; substitutions only occurred for products with similar indications.

Healthcare professionals' attitudes of implementing a chemotherapy electronic prescribing system: A mixed methods study

PURPOSE

Recent research has investigated the attitudes of healthcare professionals when implementing electronic healthcare systems such as electronic medical records or electronic prescribing in primary care. There is limited research on implementation of electronic prescribing in secondary care and no published research exploring implementation of systemic-anticancer therapy (includes chemotherapy, TKIs, monoclonal antibodies, etc) electronic prescribing. By considering what attitudes healthcare professionals had towards the implementation of systemic-anticancer therapy (SACT) electronic prescribing systems, recommendations could be developed and used to aid successful future implementations.

METHODS

This mixed methods study was in three phases. The first phase was a qualitative exploration of attitudes of healthcare professionals towards the implementation of a systemic-anticancer therapy electronic prescribing system, with the development of a questionnaire based on these findings. This was followed by a quantitative second phase where the results from the questionnaire were used to assess if the qualitative results could be generalised to a larger population. Further progression in phase three looked at developing recommendations based on the factors found in order to aid future implementations for hospitals.

RESULTS

Thirteen factors were found relating to attitudes of healthcare staff when implementing systemic-anticancer therapy electronic prescribing. Nine of these factors were cited by other researchers when implementing other electronic healthcare systems. Four factors appeared to be specific to systemic-anticancer therapy electronic prescribing implementations. Nineteen recommendations were proposed when implementing a systemic-anticancer therapy electronic prescribing system.

CONCLUSION

This is the first study, to our knowledge, to examine the attitudes of healthcare professionals when implementing a systemic-anticancer therapy electronic prescribing system and the first to define important factors and list recommendations to manage these.

Does prescribing of immediate release oxycodone by emergency medicine physicians result in persistence of Schedule 8 opioids following discharge?

OBJECTIVES

To identify the prevalence of oxycodone immediate release (IR) prescribed during an ED admission and the persistence of Schedule 8 (S8) opioids following an ED admission.

METHODS

A retrospective cross-sectional audit was undertaken reviewing all admission at the ED of the Royal Hobart Hospital, Tasmania, between 1 August and 30 September 2016. The admissions lists for ED were cross matched with the narcotic registers for oxycodone IR (the most commonly supplied S8 in ED) to identify how many patients received IR oxycodone during their ED admissions. Determination of the persistence of opioid use in opioid naïve patients was then undertaken using the Tasmanian real time reporting database of all S8 opioid dispensed in Tasmania (DAPIS).

RESULTS

There were 8432 ED admissions for 7065 patients aged over 13 years. IR oxycodone was prescribed during 1049 of these admissions (12.4%). Of the patients who were not taking regularly prescribed S8 opioids prior to their ED admission (n = 853), 48 patients (5.6%) were taking S8 opioids at both 2 and 6 months following their ED admission. Thirty patients (2.8%) were approved for authorities for long-term opioids for non-cancer pain.

CONCLUSION

These findings suggest that prescribing of IR oxycodone within ED is lower than previous studies. Additionally, the progression to regular chronic opioid use following an ED admission where IR oxycodone was given was relatively low with 3.0% of opioid naïve patients being approved for indications related to chronic non-cancer pain in the following 6 months.

Implementing target range oxygen in critical care: A quality improvement pilot study

Background

Iatrogenic hyperoxaemia is common on critical care units and has been associated with increased mortality. We commenced a quality improvement pilot study to analyse the views and practice of critical care staff regarding oxygen therapy and to change practice to ensure that all patients have a prescribed target oxygen saturation range.

Methods

A baseline measurement of oxygen target range prescribing was undertaken alongside a survey of staff attitudes. We then commenced a programme of change, widely promoting an agreed oxygen target range prescribing policy. The analyses of target range prescribing and staff survey were repeated four to five months later.

Results

Thirty-three staff members completed the baseline survey, compared to 29 in the follow-up survey. There was no discernible change in staff attitudes towards oxygen target range prescribing. Fifty-four patients were included in the baseline survey and 124 patients were assessed post implementation of changes. The proportion of patients with an oxygen prescription with a target range improved from 85% to 95% (χ² = 5.17, p = 0.02) and the proportion of patients with an appropriate prescribed target saturation range increased from 85% to 91% (χ² = 1.4, p = 0.24). The improvement in target range prescribing was maintained at 96% 12 months later.

Conclusions

The introduction and promotion of a structured protocol for oxygen prescribing were associated with a sustained increase in the proportion of patients with a prescribed oxygen target range on this unit.