Opioid prescribing by dentists in Manitoba, Canada: A longitudinal analysis

BACKGROUND

Overuse of opioids has become a health crisis in the United States and Canada. Opioid prescribing practices have subsequently come under scrutiny, with limited study regarding prescribing patterns of dentists.

METHODS

A longitudinal analysis was conducted on all adult patients to whom an opioid was dispensed from 2014 through 2017 in Manitoba, Canada. Rates of dental opioid prescribing, milligram morphine equivalents (MMEs) per prescription, and guideline adherence were determined. Additional analyses evaluated the contribution of dentist prescribing to first opioid use and opioid use 90 days before and after first dental opioid prescription.

RESULTS

Dentist prescriptions accounted for 3.8% of all opioid prescriptions and 0.58% of total MMEs. Codeine with acetaminophen combinations were the primary opioid prescribed (97.4%), followed by tramadol/acetaminophen (1.7%) and oxycodone with acetaminophen (0.7%). Overall, 30 or less tablets were supplied in 96.1% of prescriptions. Prescriptions were written for 5 or less days in 89.1% of cases and for 7 or less days in 95.2% of cases. In the 90-day before-after analysis, 87.8% of patients received only 1 prescription from their dentist, with an additional 9.8% receiving only 2 prescriptions. Dentists were responsible for 20.6% of first opioid prescriptions, with 5.6% written for 50 or more MMEs per day.

CONCLUSIONS

Compared with available guidelines, prescribed quantities were mostly appropriate, suggesting that the overall contribution of dentists to opioid overuse is limited.

PRACTICAL IMPLICATIONS

Dental opioid stewardship can be encouraged through an enhanced regulatory monitoring program with local review to guide efforts to further improve opioid prescribing. Continued efforts are warranted to prescribe smaller quantities and for greater avoidance of opioid use for dental pain.

What are the clinical practice experiences of specialist and advanced paramedics working in emergency department roles? A qualitative study

Aim:

Little is known about paramedics who have left the ambulance service to work in emergency departments (EDs). This study sought to explore the lived experiences of paramedics working in specialist/advanced ED roles, focusing on role transition, influences on effective clinical practice and perceptions of role optimisation. A secondary aim of the study was to make recommendations on the future development of specialist/advanced ED roles for paramedics.

Methods:

This was a qualitative study utilising descriptive phenomenology to collect and describe the lived experiences of participants via semi-structured interviews. The final sample comprised three emergency care practitioners (ECPs), three student ECPs and two advanced clinical practitioners (ACPs), all Health and Care Professions Council registered paramedics. Interview data were transcribed verbatim and analysed using inductive thematic analysis.

Results:

Conclusions:

While role transition to the ED represents a turbulent period for paramedics, elements of pre-hospital paramedic practice transfer directly into ED roles and contribute to effective practice. Participants found that they were accepted and supported to work in the ED setting and spoke positively of future role expansion. A lack of access to medicines presents a significant barrier to current clinical practice and a disparity in practice between paramedics and their nursing counterparts. The change in legislation to allow independent prescribing for advanced paramedics will address some of these issues, but interim improvements are required to extend existing arrangements to paramedics, improving the quality and safety of care they provide and ultimately the patient experience.

A review of the prescribing trend of thiazide-type and thiazide-like diuretics in hypertension: A UK perspective

Thiazide diuretics have been the cornerstone of hypertension treatment for >5 decades. Most recent European and American guidelines recommend both thiazide-type and thiazide-like diuretics as first-line drugs for all patients with hypertension. In contrast, diuretics are not regarded as first-line treatment in the UK and in patients who are to be initiated on a diuretic treatment, thiazide-like molecules, such as chlortalidone and indapamide are the preferred option. This review examines the prescribing trend of the 4 most commonly prescribed thiazide diuretics for the treatment of hypertension in the UK. Prescription cost analysis data were obtained for both 2010 and 2016/2017 for each region of the UK to analyse the impact of the 2011 National Institute for Health and Care Excellence hypertension guidelines on the trend in thiazide diuretic prescribing. Overall, the prescriptions of thiazide diuretics declined over the years. Bendroflumethiazide is the most commonly prescribed diuretic in the UK and despite some geographical differences, thiazide-type diuretics are more widely used than thiazide-like. The use of indapamide increased significantly between 2010 and 2016/2017 while chlortalidone was rarely employed. Of the many factors affecting trends in prescriptions, clinical inertia, treatment adherence, availability of the products and the lack of fixed dose combinations may play a role.

Pain And The Use Of Gabapentinoids In German Nursing Home Residents - Results From An Analysis Based On Statutory Health Insurance Data

Background

Gabapentinoids (gabapentin and pregabalin) are psychoactive medications that are increasingly used for different conditions. Since there is evidence that psychotropic drugs, in general, are often inappropriately prescribed in elderly patients, we aimed to determine frequency and indications of gabapentinoid prescribing for nursing home residents.

Methods

We analyzed data from a large German statutory health insurance database. Included were records from people ≥65 years-of-age, who were admitted to a nursing home between January 2010 and December 2014. We determined the number and proportion of common indications for on- and off-label prescriptions, the most frequent co-medications, and the characteristics of patients and prescribers.

Results

Of 127,277 residents, 9539 (7.5%) received gabapentinoids and 4852 initiated treatment (4.0%; with 66.3% pregabalin). Median age of gabapentinoid initiators was 84 years (78.5% females). In these users, on-label prescribing was found in 57.4%, predominantly for neuropathic pain. Other painful conditions were also chief causes (84.7%) for off-label prescribing. Gabapentinoids were mainly started by general practitioners (64.5%) while pain specialists contributed <2%. Forty-six percent of users received additional opioids and in 27.5% gabapentinoids were prescribed only once.

Conclusion

Gabapentinoids were frequently used in nursing home residents. Regular co-prescribing with opioids and psychotropic drugs might indicate employment to improve pain or assist treatment of conditions that are frequently associated with disruptive behavior such as dementia. However, more research is needed to better understand decision-making regarding gabapentinoid prescribing, especially in view of aggressive marketing, uncertain analgesic effects, problematic side effects, and uncritical use in the elderly.

Nurse Prescribing-Readiness of Polish Nurses to Take on New Competencies-A Cross-Sectional Study

From January 2016, nurses in Poland received new competencies for prescribing. The work is the first in Poland to elaborate on the subject of nurses' readiness to learn and develop in the context of new nursing rights regarding autonomous prescription of medication and continuation of the prescription for medication. The aim of the study is to analyze the readiness of Polish nurses to learn and develop in the context of new competencies to write prescriptions. The research was conducted among 756 nurses. The standardized questionnaire (Readiness of Employees for Learning and Development) was used. For all subscales of readiness for learning and development, average scores prevailed. The readiness to write prescriptions was significantly related to the level of openness to changes in the work environment (A1 scale), self-evaluation of past educational development (C5 scale) and educational and professional goals alignment- employee and company (scale D2) and increasing the readiness of nurses to practice all of the aforementioned agents, in particular medical devices. The readiness of nurses to learn and develop at all levels of the subscales was on an average level. Younger nurses, with a shorter seniority, having higher education and additional qualifications had a higher readiness to prescribe medications and write prescriptions. The higher readiness for learning and development was matched by a greater readiness to prescribe. The results obtained can be used to plan training and courses, as well as to create special pro-development programs, which may increase the nurses' involvement in personal and professional development.

Understanding the Context of High- and Low-Testosterone Prescribing Facilities in the Veterans Health Administration (VHA): a Qualitative Study

BACKGROUND

Inappropriate testosterone use and variations in testosterone prescribing patterns exist in the Veterans Health Administration (VHA) despite the presence of clinical guidelines.

OBJECTIVE

We examined system and clinician factors that contribute to patterns of potentially inappropriate testosterone prescribing in VHA.

DESIGN

Qualitative study using a positive deviance approach to understand practice variation in high- and low-testosterone prescribing sites.

PARTICIPANTS

Twenty-two interview participants included primary care and specialty clinicians, key opinion leaders, and pharmacists at 3 high- and 3 low-testosterone prescribing sites.

APPROACH

Semi-structured phone interviews were conducted, transcribed, and coded using a priori theoretical constructs and emergent themes. Case studies were developed for each site and a cross-case matrix was created to evaluate variation across high- and low-prescribing sites.

KEY RESULTS

We identified four system-level domains related to variation in testosterone prescribing: organizational structures and processes specific to testosterone prescribing, availability of local guidance on testosterone prescribing, well-defined dissemination process for local testosterone polices, and engagement in best practices related to testosterone prescribing. Two clinician-level domains were also identified, specifically, structured initial testosterone prescribing process and specified follow-up testosterone prescribing process. High- and low-testosterone prescribing sites systematically varied in the four system-level domains, while the clinician-level domains looked similar across all sites. The third high-prescribing site was unusual in that it exhibited the four domains similar to the 3 low-prescribing sites at the time of our visit. This site had greatly reduced its prescribing of testosterone in the interim.

CONCLUSIONS

Findings suggest that local organizational factors play an important role in influencing prescribing. Sites have the potential to transform their utilization patterns by providing access to specialty care expertise, an electronic health record-based system to facilitate guideline-concordant prescribing, well-defined dissemination processes for information, guidance from multiple sources, and clarity regarding best practices for prescribing.

Assessing the impact of procedure-specific opioid prescribing recommendations on opioid stewardship following pelvic organ prolapse surgery

BACKGROUND

Nationally, there is increasing concern regarding the volume of opioid medications prescribed postoperatively and the rate of prescription opioid-related adverse events. In evaluation of this, several reports have identified significant variability in postoperative opioid-prescribing patterns, including quantities exceeding patient's needs, especially after minor surgical procedures. However, data regarding patient's postoperative opioids needs following surgery for pelvic organ prolapse are sparse.

OBJECTIVE

To design procedure-specific opioid-prescribing recommendations for pelvic organ prolapse surgeries and evaluate their impact on opioid stewardship.

STUDY DESIGN

We prospectively evaluated opioid-prescribing patterns, patient use, medication refills, and patient satisfaction in women undergoing prolapse surgery (ie, vaginal, abdominal, or robotic) during an 8-month time period. Two cohorts of women, stratified by whether they had surgery before or after implementation of procedure-specific opioid-prescribing recommendations, were evaluated. Postoperative opioid usage (assessed via pill count), medication refills, and satisfaction with pain management after hospital dismissal were evaluated by telephone call 2 weeks after surgery. Postoperative opioid prescribing and use were recorded after conversion to oral morphine equivalents.

RESULTS

Overall, 96 women were included, 57 in the initial baseline cohort, and 39 following implementation of the prescribing recommendations. In the initial cohort, 32.8% of the prescribed oral morphine equivalents (3607/11,007 mg) were consumed. Following implementation of the prescribing recommendations, median oral morphine equivalents prescribed decreased from 200 mg oral morphine equivalents (interquartile range 150, 225) to 112.5 mg oral morphine equivalents (interquartile range 22.5, 112.5; P<.0001). The total oral morphine equivalents prescribed decreased by 45% when compared with the volume that would have been prescribed before implementing the recommendations. The amount of leftover opioids per patient significantly decreased as well (P<.0001). Pain medication refills increased after the intervention (18% vs 3.5%; P=.03), whereas satisfaction scores were similar in both cohorts (P=.87).

CONCLUSIONS

By using procedure-specific opioid prescribing recommendations, we decreased the number of opioids prescribed at hospital dismissal by roughly one half. Decreased opioid prescribing did not adversely impact patient satisfaction.

Prescribing trends of gabapentin, pregabalin, and oxycodone: a secondary analysis of primary care prescribing patterns in England

Background

The risk of iatrogenic harm from the use and misuse of prescription drugs such as gabapentin, pregabalin, and oxycodone is substantial. In recent years, deaths associated with these drugs in England have increased.

Aim

To characterise general practice prescribing trends for gabapentin, pregabalin, and oxycodone — termed dependence forming medicines (DFM) — in England and describe potential drivers of unwarranted variation (that is, very high prescribing).

Design & setting

This study is a retrospective secondary analysis of open source, publicly available government data from various sources pertaining to primary care demographics and prescriptions.

Method

This study used 5 consecutive years (April 2013–March 2018) of aggregate data to investigate longitudinal trends of prescribing and variation in prescribing trends at practice and clinical commissioning group (CCG) level.

Results

Annual prescriptions of gabapentin, pregabalin, and oxycodone increased each year over the period. Variation in prescribing trends was associated with GP practice deprivation quintile, where the most deprived GP practices prescribed 313% (P<0.001) and 238% (P<0.001) greater volumes of gabapentin and pregabalin per person respectively, than practices in the least deprived quintile. The highest prescribing CCGs of each of these drugs were predominantly in northern and eastern regions of England.

Conclusion

Substantial increases in gabapentin, pregabalin, and oxycodone prescriptions are concerning and will increase iatrogenic harm from drug-related morbidity and mortality. More research is needed to understand the large variation in prescribing between general practices, and to develop and implement interventions to reduce unwarranted variation and increase the appropriateness of prescribing of these drugs.

Postoperative Opioid Use and Pain Management Following Otologic and Neurotologic Surgery

OBJECTIVES

The topic of prescription opioid overuse remains a growing concern in the United States. Our objective is to provide insight into pain perception and opioid use based on a patient cohort undergoing common otologic and neurotologic surgeries.

STUDY DESIGN

Prospective observational study with patient questionnaire.

SETTING

Single academic medical center.

SUBJECTS AND METHODS

Adult patients undergoing otologic and neurotologic procedures by two fellowship trained neurotologists between June and November of 2018 were included in this study. During first postoperative follow-up, participants completed a questionnaire assessing perceived postoperative pain and its impact on quality of life, pain management techniques, and extent of prescription opioid use.

RESULTS

A total of 47 patients met inclusion and exclusion criteria. The median pain score was 3 out of 10 (Interquartile Range [IQR] = 2-6) with no significant gender differences (P = .92). Patients were prescribed a median of 15.0 (IQR = 10.0-15.0) tablets of opioid pain medication postoperatively, but only used a median of 4.0 (IQR = 1.0-11.5) tablets at the time of first follow-up. Measured quality of life areas included sleep, physical activity, work, and mood. Sleep was most commonly affected, with 69.4% of patients noting disturbances.

CONCLUSIONS

This study suggests that practitioners may over-estimate the need for opioid pain medication following otologic and neurotologic surgery. It also demonstrates the need for ongoing patient education regarding opioid risks, alternatives, and measures to prevent diversion.

Antibiotic Prescribing Patterns at a Leading Referral Hospital in Kenya: A Point Prevalence Survey

Objective:

Antibiotics are essential with inappropriate use leading to antimicrobial resistance (AMR). Currently, little is known about antibiotic use among hospitals in Kenya, which is essential to tackle as part of the recent national action plan addressing rising AMR rates. Consequently, the objective was to overcome this gap in a leading referral hospital in Kenya. The findings will subsequently be used to develop quality improvement programs for this and other hospitals in Kenya.

Methods:

This was a point prevalence survey. Data on antibiotic use were abstracted from patient medical records by a pharmacy team.

Findings:

The prevalence of antibiotic prescribing was 54.7%, highest in the intensive care unit and isolation wards. Most antibiotics were for treatment (75.4%) rather than prophylaxis (29.0%). The majority of patients on surgical prophylaxis were on prolonged duration (>1 day), with only 9.6% on a single dose as per current guidelines. Penicillins (46.9%) followed by cephalosporins (44.7%) were the most prescribed antibiotic classes. The indication for antibiotic use was documented in only 37.3% of encounters. Generic prescribing was 62.5% and empiric prescribing was seen in 82.6% of encounters. Guideline compliance was 45.8%.

Conclusion:

Several areas for improvement were identified including addressing prolonged duration for prophylaxis, extensive prescribing of broad-spectrum antibiotics, high rates of empiric prescribing, and lack of documenting the indication for antimicrobials. Initiatives are ongoing to address this with pharmacists playing a key role.

Determination of combination therapy prescribing patterns for the treatment of acute agitation in psychiatric patients: A regression model of patient diagnoses and demographics

Introduction

Guidelines for the treatment of acute agitation typically recommend monotherapy with an antipsychotic or a benzodiazepine, but combination therapy is frequently used in practice. We created a regression model to identify which factors lead to the prescribing of combination therapy for acute agitation on a psychiatry unit.

Methods

We collected retrospective data from hospitalized patients in the psychiatry unit. An a priori alpha of 0.05 was used for binary logistic regression models to determine if and how the number of prescribed medications for acute agitation was influenced by: age, sex, race, cardiovascular comorbidities, and psychiatric diagnoses.

Results

We identified 1998 encounters from 1200 patients. Patients are significantly more likely to be prescribed combination therapy if they are young, male, and of non-white race or have a diagnosis of central nervous system stimulant use, hallucinogen use, depression, bipolar, cluster B personality, or psychosis. Patients are significantly more likely to be prescribed monotherapy if they have cardiovascular comorbidity or have neurocognitive disorder.

Discussion

Several demographic or diagnostic factors predict combination therapy prescribing. Acute agitation guidelines should be reviewed to include more clear instructions on combination therapy use.

The Association Between Patient Visit Demographics and Opioid Analgesic Received in the Emergency Department

Introduction: Minimal research has been conducted on the prescribing patterns of emergency room physicians. The opioid epidemic is a well-known public health crisis and increased knowledge of providers’ tendencies to prescribe opioids over other analgesia may help to update guidelines, improve patient safety, and lower the amount of opioid diversion and death from overdose. The purpose of this study was to determine the association between patient visit demographics and prescribed opiate analgesics.

Methods: We conducted a retrospective study analyzing adult patient visits that were seen in the emergency setting for acute pain including chest pain, back pain, abdominal pain, headache, face/tooth/ear, or musculoskeletal pain, utilizing the 2011-2016 National Hospital Ambulatory Medical Care Survey Emergency Department Patient Record dataset. We analyzed the relationship between various patient visit characteristics and whether opiate analgesics were given or prescribed. 

Results: Our study included 73,983 visits for pain, representing an estimated 407 million weighted visits over the study period. We found that those who received opiates were more likely to be female, 62.9% vs. 60.2% and more likely to be white, 74.2% vs. 71.3 %. Furthermore, visits that received opiates were more likely to be younger, have private insurance, and be in increased pain (all P-values = 0.000). 

Conclusion: We found that certain patient visit characteristics - including being female, white, younger, and private insurance - were given opiates more in the emergency department. Females have been found to report more pain, the elderly have special considerations regarding pain medications (including the risk of delirium and drug-drug interactions), while insurance status may be confounded by age (Medicare being a large portion of government insurance). However, explanations for differences in prescription rates by race could not be easily discerned.

Drug-related problems in prescribing for coronary artery diseases in Vietnam: cross-sectional study

OBJECTIVES

To determine the prevalence, patterns and determinants of drug-related problems (DRPs) in prescribing for coronary artery diseases (CADs) in Vietnam.

METHODS

Retrospective cross-sectional study on outpatients with CADs at a general hospital in Can Tho, Vietnam. DRPs were classified according to Pharmaceutical Care Network Europe definitions. We determined the prevalence and patterns of DRPs. Logistic regression was used to identify the determinants of DRPs.

RESULTS

Among 683 patients (mean age 63.4; 64.3% female), the prevalence of DRPs was 61.1%. DRPs comprised inappropriate indication (3.5%), inappropriate dosage (22.2%), wrong frequency of use (24.2%), wrong time of taking medications (4.1%), taking medications at the wrong time around meals (19.2%) and drug interactions (19.3%). Patients who took ≥ 5 drugs were more likely to have DRPs (adjusted odds ratio = 1.96; 95% confidence interval = 1.31-2.93). Patients without health insurance were more likely to have inappropriate indication (ORa = 2.93; 95%CI = 1.28-6.70). Taking medications at inappropriate times around meals was common among men (ORa = 1.82; 95%CI = 1.23-2.69) and among those with health insurance (ORa = 1.66; 95%CI = 1.05-2.63). Patients < 65 years old were more likely to be prescribed inappropriate doses (ORa = 1.67; 95%CI = 1.15-2.45). Prescriptions with ≥ 5 drugs were more likely to be taken at inappropriate frequency (ORa = 1.87; 95%CI = 1.09-3.21) and to cause drug interactions (ORa = 6.48; 95%CI = 2.59-16.24).

CONCLUSIONS

DRPs are common among patients with CADs in Vietnam. The number of DRPs increases with the number of drugs in prescriptions. Further studies should identify other potential determinants of DRPs and effective interventions to improve prescribing practice in Vietnam.

Analysis of English general practice level data linking medication levels, service activity and demography to levels of glycaemic control being achieved in type 2 diabetes to improve clinical practice and patient outcomes

OBJECTIVE

Evaluate relative clinical effectiveness of treatment options for type 2 diabetes mellitus (T2DM) using a statistical model of real-world evidence within UK general practitioner practices (GPP), to quantify the opportunities for diabetes care performance improvement.

METHOD

From the National Diabetes Audit in 2015-2016 and 2016-2017, GPP target glycaemic control (TGC-%HbA1c ≤58 mmol/mol) and higher glycaemic risk (HGR -%HbA1c results >86 mmol/mol) outcomes were linked using multivariate linear regression to prescribing, demographics and practice service indicators. This was carried out both cross-sectionally (XS) (within year) and longitudinally (Lo) (across years) on 35 indicators. Standardised β coefficients were used to show relative level of impact of each factor. Improvement opportunity was calculated as impact on TGC & HGR numbers.

RESULTS

Values from 6525 GPP with 2.7 million T2DM individuals were included. The cross-sectional model accounted for up to 28% TGC variance and 35% HGR variance, and the longitudinal model accounted for up to 9% TGC and 17% HGR variance. Practice service indicators including % achieving routine checks/blood pressure/cholesterol control targets were positively correlated, while demographic indicators including % younger age/social deprivation/white ethnicity were negatively correlated. The β values for selected molecules are shown as (increased TGC; decreased HGR), canagliflozin (XS 0.07;0.145/Lo 0.04;0.07), metformin (XS 0.12;0.04/Lo -;-), sitagliptin (XS 0.06;0.02/Lo 0.10;0.06), empagliflozin (XS-;0.07/Lo 0.09;0.07), dapagliflozin (XS -;0.04/Lo -;0.4), sulphonylurea (XS -0.18;-0.12/Lo-;-) and insulin (XS-0.14;0.02/ Lo-0.09;-). Moving all GPP prescribing and interventions to the equivalent of the top performing decile of GPP could result in total patients in TGC increasing from 1.90 million to 2.14 million, and total HGR falling from 191 000 to 123 000.

CONCLUSIONS

GPP using more legacy therapies such as sulphonylurea/insulin demonstrate poorer outcomes, while those applying holistic patient management/use of newer molecules demonstrate improved glycaemic outcomes. If all GPP moved service levels/prescribing to those of the top decile, both TGC/HGR could be substantially improved.

Evaluation of online clinical pharmacology curriculum resources for medical students

Aims

To identify and evaluate clinical pharmacology (CP) online curricular (e‐Learning) resources that are internationally available for medical students.

Methods

Literature searches of Medline, EMBASE and ERIC databases and an online survey of faculty members of international English language medical schools, were used to identify CP e‐Learning resources. Resources that were accessible online in English and aimed to improve the quality of prescribing specific medications were then evaluated using a summary percentage score for comprehensiveness, usability and quality, and for content suitability.

Results

Our literature searches and survey of 252 faculty (40.7% response rate) in 219 medical schools identified 22 and 59 resources respectively. After screening and removing duplicates, 8 eligible resources remained for evaluation. Mean total score was 53% (standard deviation = 13). The Australian National Prescribing Curriculum, ranked highest with a score of 77%, based primarily on very good ratings for usability, quality and suitable content.

Conclusion

Using a novel method and evaluation metric to identify, classify, and rate English language CP e‐Learning resources, the National Prescribing Curriculum was the highest ranked open access resource. Future work is required to implement and evaluate its effectiveness on prescribing competence.

Pharmacist-led, video-stimulated feedback to reduce prescribing errors in doctors-in-training: A mixed methods evaluation

Aims

To develop and evaluate a feasible, authentic pharmacist‐led prescribing feedback intervention for doctors‐in‐training, to reduce prescribing errors.

Methods

This was a mixed methods study. Sixteen postgraduate doctors‐in training, rotating though the surgical assessment unit of 1 UK hospital, were filmed taking a medication history with a patient and prescribing medications. Each doctor reviewed their video footage and made plans to improve their prescribing, supported by feedback from a pharmacist. Quantitative data in the form of prescribing error prevalence data were collected on 1 day per week before, during and after the intervention period (between November 2015 and March 2017). Qualitative data in the form of individual semi‐structured interviews were collected with a subset of participants, to evaluate their experience. Quantitative data were analysed using a statistical process chart and qualitative data were transcribed and analysed thematically.

Results

During the data collection period, 923 patient drug charts were reviewed by pharmacists who identified 1219 prescribing errors overall. Implementation of this feedback approach was associated with a statistically significant reduction in the mean number of prescribing errors, from 19.0/d to 11.7/d (estimated to equate to 38% reduction; P < .0001). Pharmacist‐led video‐stimulated prescribing feedback was feasible and positively received by participants, who appreciated the reinforcement of good practice as well as the opportunity to reflect on and improve practice.

Conclusions

Feedback to doctors‐in‐training tends to be infrequent and often negative, but this feasible feedback strategy significantly reduced prescribing errors and was well received by the target audience as a supportive developmental approach.

Optimising low-dose methotrexate for rheumatoid arthritis-A review

Methotrexate at low doses (5-25 mg/week) is first-line therapy for rheumatoid arthritis. However, there is inter- and intrapatient variability in response, with contribution of variability in concentrations of active polyglutamate metabolites, associated with clinical efficacy and toxicity. Prescribing remains heterogeneous across population groups, disease states and regimens. This review examines current knowledge of dose-response of oral methotrexate in the setting of rheumatoid arthritis, and how this could help inform dosage regimens.

Epidemiology of eating disorders in primary care in children and young people: a Clinical Practice Research Datalink study in England

OBJECTIVES

Examination of current temporal trends and clinical management patterns of eating disorders (ED) in primary care is lacking. We aimed to calculate annual incidence rates of EDs in primary care by age, sex and deprivation. We also explored the care received through referrals, psychotropic prescriptions and associated secondary care service use.

PARTICIPANTS AND SETTINGS

A retrospective electronic cohort study was conducted using the Clinical Practice Research Datalink in those aged 11-24 years between 2004 and 2014 in England (n=1 135 038).

RESULTS

A total of 4775 individuals with a first ever recorded ED diagnosis were identified. The crude incidence rate was 100.1 per 100 000 person years at risk (95% CI 97.2 to 102.9). Incidence rates were highest in females (189.3 per 100 000 person years, 95% CI 183.7 to 195.0, n=4336), 16-20 years of age (141.0 per 100 000 person years, 95% CI 135.4 to 146.9, n=2348) and individuals from the least deprived areas (115.8 per 100 000 person years (95% CI 109.3 to 122.5, n=1203). Incidence rates decreased across the study period (incidence rate ratio (IRR) 0.6, 95% CI 0.5 to 0.8), particularly for individuals with bulimia nervosa (IRR 0.5, 95% CI 0.3 to 0.7) and from the most deprived areas (IRR 0.5, 95% CI 0.4 to 0.7). A total of 17.4% (95% CI 16.3 to 18.5, n=831) of first ever recorded ED cases were referred from primary to secondary care. 27.1% (95% CI 25.9 to 28.4, n=1294) of individuals had an inpatient admission 6 months before or 12 months after an incident ED diagnosis and 53.4% (95% CI 52.0 to 54.9, n=2550) had an outpatient attendance. Antidepressants were the most commonly prescribed psychotropic medication.

CONCLUSIONS

New ED presentations in primary care are reducing. Understanding the cause of this decrease (coding behaviours, changes in help-seeking or a genuine reduction in new cases) is important to plan services, allocate resources and deliver effective care.

Antidepressant Prescribing Patterns in Heart Failure Patients at Residential Aged Care Facilities in Australia: A Cross-sectional Study

Objective:

Depression is associated with poor outcomes following heart failure. Information regarding the use and effectiveness of antidepressants in heart failure patients is lacking. This study aims to evaluate the prescribing patterns of antidepressants in patients with heart failure residing in aged care facilities.

Methods:

This study was a cross-sectional analysis of de-identified Australian Residential Medication Management Reviews conducted between January 2016 and April 2017. SPSS version 24 software was used to analyze the data. Descriptive statistics were used to summarize age, gender, and antidepressants use. Wilcoxon signed-rank test was used to assess the differences in antidepressant prescribing between patients with and without heart failure.

Findings:

Of 4369 patients, 980 (22.4%) had heart failure. Of those with heart failure, 410 (41.8%) were using at least one antidepressant. Mirtazapine was the most commonly prescribed antidepressant in patients with heart failure (27.8%) and without heart failure (27.3%). When grouping antidepressants for class, selective serotonin reuptake inhibitors were the most commonly prescribed in both groups. There was no statistically significant difference in antidepressant prescribing patterns between patients with and without heart failure (P = 0.961).

Conclusion:

Mirtazapine was the most commonly used antidepressant in heart failure patients residing in aged care facilities. This study has highlighted a need for a randomized controlled trial to evaluate the efficacy and safety of mirtazapine in the management of depression in patients with heart failure.

Exploring Perspectives on Antimicrobial Use in Livestock: A Mixed-Methods Study of UK Pig Farmers

Increasing levels of antimicrobial resistance in human and veterinary medicine have raised concerns over the irresponsible use of antimicrobials. The role of administering antimicrobials in food producing animals most frequently falls to the farmer, therefore it is essential that their use of antimicrobials is both optimal and responsible. This study sought in-depth information on the drivers behind antimicrobial use behaviors and farmer attitudes to responsible use using a mixed-methodological approach. Initially, in-depth semi-structured interviews were conducted with a purposively selected sample of farmers (n = 22). A thematic analysis approach was taken to identify key themes from these qualitative data. The generalizability and variation of these themes was then tested on a larger randomly selected sample of pig farmers through a questionnaire study (n = 261). The influences behind antimicrobial use were complex with multiple drivers motivating decisions. There was no consensual opinion on what farming systems resulted in either a low or high antimicrobial requirement however, farmers reported that good management practices, low stocking densities, and a high health status were associated with low antimicrobial use. Farmers expressed desire to avoid the long-term use of in-feed antimicrobials, but identified barriers to discontinuing such behaviors, such as pig morbidity, mortality, and economic losses. The high cost of antimicrobials was described as a motivation toward seeking alternative methods of controlling disease to prophylactic use; however, this expense was balanced against the losses from an increased burden of disease. The high financial costs involved in pig production alongside the economic uncertainty of production and pressure from retailers, were identified as limiting the scope for improvements in pig accommodation and facilities which could reduce the antimicrobial requirements on farm. Long-term, sustainable and economically stable relationships between retailers and farmers may allow farmers to make necessary investments in improving management and housing in order to reduce antimicrobial use. Greater use and more widespread deployment of effective vaccinations were highlighted by farmers as being a feasible alternative to antimicrobial use in preventing disease.

Prescribers' views and experiences of using direct acting oral anticoagulants in the management of nonvalvular atrial fibrillation: A survey in remote and rural Scotland

AIMS

A recent systematic review highlighted the lack of robust studies on prescribers' perspectives of direct-acting oral anticoagulants (DOACs) for nonvalvular atrial fibrillation. The aim was to determine prescribers' views and experiences of prescribing DOACs.

METHODS

A cross-sectional survey of prescribers in a remote and rural area of Scotland. Survey items were: demographics; prescribing of DOACs; views of potential influences on DOAC prescribing; knowledge of prescribing guidelines; and experiences. Items on potential influences were based on the Theoretical Domains Framework. Data were analysed using descriptive and inferential statistics, and content analysis of responses to open questions. Principal component analysis was performed on the items of potential influences.

RESULTS

In total, 154 responses were received, 120 (77.9%) from doctors, 18 (11.7%) from nurse prescribers and 10 (6.4%) from pharmacist prescribers (6 missing). Principal component analysis of the Theoretical Domains Framework items of potential influences gave 4 components. Component scores for (i) role of professionals, their knowledge and skills and (ii) influences on prescribing were positive. Those for (iii) consequences of prescribing and (iv) monitoring for safety and effectiveness were more neutral. There were low levels of agreement for statements relating to DOACs being more effective, safer and cost-effective than warfarin. There were similar responses around the complexity of bleeding management and detection of over and under-anticoagulation.

CONCLUSION

This study has identified several key issues of DOAC prescribing (e.g. bleeding management) hence further emphasis is required in continuing professional development and during guideline implementation and evaluation.

Emergency Physician Opioid Prescribing and Risk of Long-term Use in the Veterans Health Administration: an Observational Analysis

BACKGROUND

Treatment by high-opioid prescribing physicians in the emergency department (ED) is associated with higher rates of long-term opioid use among Medicare beneficiaries. However, it is unclear if this result is true in other high-risk populations such as Veterans.

OBJECTIVE

To estimate the effect of exposure to high-opioid prescribing physicians on long-term opioid use for opioid-naïve Veterans.

DESIGN

Observational study using Veterans Health Administration (VA) encounter and prescription data.

SETTING AND PARTICIPANTS

Veterans with an index ED visit at any VA facility in 2012 and without opioid prescriptions in the prior 6 months in the VA system ("opioid naïve").

MEASUREMENTS

We assigned patients to emergency physicians and categorized physicians into within-hospital quartiles based on their opioid prescribing rates. Our primary outcome was long-term opioid use, defined as 6 months of days supplied in the 12 months subsequent to the ED visit. We compared rates of long-term opioid use among patients treated by high versus low quartile prescribers, adjusting for patient demographic, clinical characteristics, and ED diagnoses.

RESULTS

We identified 57,738 and 86,393 opioid-naïve Veterans managed by 362 and 440 low and high quartile prescribers, respectively. Patient characteristics were similar across groups. ED opioid prescribing rates varied more than threefold between the low and high quartile prescribers within hospitals (6.4% vs. 20.8%, p < 0.001). The frequency of long-term opioid use was higher among Veterans treated by high versus low quartile prescribers, though above the threshold for statistical significance (1.39% vs. 1.26%; adjusted OR 1.11, 95% CI 0.997-1.24, p = 0.056). In subgroup analyses, there were significant associations for patients with back pain (adjusted OR 1.25, 95% CI 1.01-1.55, p = 0.04) and for those with a history of depression (adjusted OR 1.28, 95% CI 1.08-1.51, p = 0.004).

CONCLUSIONS

ED physician opioid prescribing varied by over 300% within facility, with a statistically non-significant increased rate of long-term use among opioid-naïve Veterans exposed to the highest intensity prescribers.

The role of undergraduate teaching, learning and a national prescribing safety assessment in preparation for practical prescribing: UK medical students' perspective

AIMS

To investigate medical students' perspectives on the influence of their undergraduate course and the UK prescribing safety assessment (PSA) on the acquisition of practical prescribing skills.

METHODS

An online questionnaire comprising multiple choice and open-ended questions was available to UK medical students in years 3, 4 and 5. Descriptive statistics and thematic analysis were completed.

RESULTS

In total, 1023 medical students from 25 UK medical schools responded: 22% (3rd year), 37% (4th year) and 41% (final year). A minority of medical students believed that their medical course prepared them sufficiently for practical prescribing (36.4%, n = 372, 95% confidence interval [CI] = 32-41%), 52.6%, of students thought that practical prescribing should be introduced into the curriculum earlier (n = 538, CI = 48-57%), and 73.7% reported that a more consistent approach to the teaching and learning of practical prescribing might be beneficial (n = 754, CI = 71-77%). An awareness of the national PSA was high (86.5%, n = 885), particularly amongst final year students (98.3%, n = 413, CI = 97-100%); 67.4% of all students (n = 690, CI = 64-71%) and 72.1% (n = 303) of final year students perceived that the PSA will improve or had improved their practical prescribing skills.

CONCLUSIONS

The majority of medical students perceive that their undergraduate course does not adequately prepare them for practical prescribing. Many believe that there is some merit in introducing practical prescribing teaching earlier in the curriculum and medical schools adopting a more consistent approach. Among medical students, the PSA is thought to have a positive influence on prescribing skills learning. These data might be useful in developing a programme of study dedicated to practical prescribing.