Decreases and Pronounced Geographic Variability in Antibiotic Prescribing in Medicaid

Antibiotic resistance is a persistent and growing concern. Our objective was to analyze antibiotic prescribing in the United States (US) in the Medical Expenditure Panel System (MEPS) and to Medicaid patients. We obtained MEPS prescriptions for eight antibiotics from 2013 to 2020. We extracted prescribing rates per 1000 Medicaid enrollees for two years, 2018 and 2019, for four broad-spectrum (azithromycin, ciprofloxacin, levofloxacin, and moxifloxacin) and four narrow-spectrum (amoxicillin, cephalexin, doxycycline, and trimethoprim-sulfamethoxazole) antibiotics. Antibiotic prescriptions in MEPS decreased from 2013 to 2020 by 38.7%, with a larger decline for the broad (-53.7%) than narrow (-23.5%) spectrum antibiotics. Antibiotic prescriptions in Medicaid decreased by 6.7%. Amoxicillin was the predominant antibiotic, followed by azithromycin, cephalexin, trimethoprim-sulfamethoxazole, doxycycline, ciprofloxacin, levofloxacin, and moxifloxacin. Substantial geographic variation in prescribing existed, with a 2.8-fold difference between the highest (Kentucky = 855/1000) and lowest (Oregon = 299) states. The South prescribed 52.2% more antibiotics (580/1000) than the West (381/1000). There were significant correlations across states (r = 0.81 for azithromycin and amoxicillin). This study identified sizable disparities by geography in the prescribing rates of eight antibiotics with over three-fold state-level differences. Areas with high prescribing rates, particularly for outpatients, may benefit from stewardship programs to reduce potentially unnecessary prescribing.

Influences of Software Changes on Oxycodone Prescribing at an Australian Tertiary Emergency Department: A Retrospective Review

Opioid prescribing and dispensing from emergency departments is a noteworthy issue given widespread opioid misuse and diversion in many countries, contributing both physical and economic harm to the population. High patient numbers and the stochastic nature of acute emergency presentations to emergency departments (EDs) introduce challenges for prescribers who are considering opioid stewardship principles. This study investigated the effect of changes to electronic prescribing software on prescriptions with an auto-populated quantity of oxycodone immediate release (IR) from an Australian tertiary emergency department following the implementation of national recommendations for reduced pack sizes. A retrospective review of oxycodone IR prescriptions over two six-month periods between 2019 and 2021 was undertaken, either side of a software adjustment to reduce the default quantities of tablets prescribed from 20 to 10. Patient demographic details were collected, and prescriber years of practice calculated for inclusion in linear mixed effects regression modelling. A reduction in the median number of tablets prescribed per prescription following the software changes (13.5 to 10.0, p < 0.001) with little change in the underlying characteristics of the patient or prescriber populations was observed, as well as an 11.65% reduction in the total number of tablets prescribed. The prescriber's years of practice, patient age and patient sex were found to influence increased prescription sizes. Reduced quantity of oxycodone tablets prescribed was achieved by alteration of prescribing software prefill parameters, providing further evidence to support systems-based policy interventions to influence health care providers behaviour and to act as a forcing function for prescribers to consider opioid stewardship principles.

'This wretched state': Robert Burns's illness and the daybook of Charles Fleeming

While now known globally as Scotland's national poet, in November 1781 the daybook of surgeon Charles Fleeming simply records him as 'Robert Burns, Lint Dresser'. Discovered in the 1950s, the daybook documents Fleeming's treatment of Burns during a period of illness which would have a profound impact on the poet's life and creative output. The book's discovery added to the theories about the nature of Burns's illness, often at odds with Burns's own later descriptions. This paper presents a fresh examination of Burns's treatment, challenging those theories by considering Fleeming's prescriptions in the context of key medical authorities of the time. In considering Burns's entry in the daybook in its entirety, the wider value of Fleeming's daybook as a private record of medical practice at the time is highlighted, pointing to the potential value of this and other such volumes as underappreciated archival research material.

Practice pharmacists and their influence on prescribing in UK general practice: a cross-sectional study

OBJECTIVES

At the time of the survey, just over 2000 pharmacists were employed in UK general practice. Little is known about their influence on prescribing, and more specifically, the extent of their use of Audit and Feedback (A&F), an evidence-based method for behaviour change. This study aimed to explore pharmacists' current influence on prescribing in UK general practice.

METHODS

A cross-sectional, online survey was open to general practice pharmacists in England, Northern Ireland, Scotland, and Wales between 9 September 2021 and 31 October 2021. The survey comprised 36 items, informed by the literature, including multiple choice and free-text questions about pharmacist responsibilities, involvement in prescribing audits (including use of A&F), use of prescribing guidelines, beliefs about influence on prescribing, and access to training and support. Descriptive statistics and frequencies were generated, and parametric analyses were conducted.

KEY FINDINGS

In total, 155 responses were received from pharmacists in diverse practice locations, with a wide range of practice pharmacist experience. The majority (80%, n = 121) conducted prescribing audits, but only 21% (n = 32) reported undertaking A&F. Most respondents (90%, n = 140) used guidelines to inform their work, and 75% (n = 116) would welcome training on influencing prescribing. Pharmacists using A&F were more likely to believe in their ability to influence prescribing and to acknowledge this activity as part of their role.

CONCLUSION

Despite substantial evidence of its effectiveness, A&F is under-used by practice pharmacists. An increased awareness and enablement of practice pharmacists in effective techniques might promote greater evidence-based prescribing in general practice.

Effect of Best Practice Alert (BPA) on Post-Discharge Opioid Prescribing After Minimally Invasive Hysterectomy: A Quality Improvement Study

Purpose

The aim of this study was to describe the effectiveness of an electronic health record best practice alert (BPA) in decreasing gynecologic post-discharge opioid prescribing following benign minimally invasive hysterectomy.

Patients and Methods

The BPA triggered for opioid orders >15 tablets. Prescribers' options included (1) decrease to 15 ≤ tablets; (2) remove the order/utilize a defaulted order set; or (3) override the alert.

Results

332 patients were included. The BPA triggered 29 times. The following actions were taken among 16 patients for whom the BPA triggered: "override the alert" (n=13); "cancel the alert" (n=2); and 'remove the opioid order set' (n=1). 12/16 patients had discharge prescriptions: one patient received 20 tablets; two received 10 tablets; and nine received 15 tablets. Top reasons for over prescribing included concerns for pain control and lack of alternatives.

Conclusion

Implementing a post-discharge opioid prescribing BPA aligned opioid prescribing following benign minimally invasive hysterectomy with guideline recommendations.

Exploring the challenges faced by foundation doctors when prescribing high risk medicines safely during the on-call period: A qualitative study

AIMS

Errors with prescribing high-risk medicines (HRMs) have a greater propensity to cause harm than with non-HRMs. Prescribing errors arise due to multiple factors and it can be particularly challenging for junior doctors to prescribe safely during the on-call period. Knowledge regarding the challenges of prescribing HRM during the on-call period would be useful to target preventative interventions. The aim of this study was to explore the challenges encountered by foundation doctors (doctors who have graduated medical school within the last 2 years) when prescribing specific HRMs (anticoagulants, insulin and opioids) safely during the on-call period.

METHODS

Six focus groups exploring the challenges of prescribing HRMs safely during the on-call period were conducted, 3 with foundation year 1 and 3 with foundation year 2 doctors from across 3 different hospitals. A thematic framework analysis based on the London Protocol was conducted.

RESULTS

Doctors described multiple challenges to prescribing HRMs safely during the on-call period including a lack of prescribing support, nursing pressure, complex prescribing tasks, unknown patients as well as individual factors such as lack of knowledge and tiredness. Many of these factors exist to some extent during the day, yet the nature of the on-call period as a fast-paced environment heightened the challenges that prescribers faced.

CONCLUSION

There are multiple challenges experienced by foundation doctors when prescribing HRMs during the on-call period. The potentially devastating consequences of errors with HRMs means that closer attention and more concern from healthcare professionals, researchers and policymakers is required to improve safe prescribing of HRMs in hospitals.

UK Prescribing Safety Assessment (PSA): The development, implementation and outcomes of a national online prescribing assessment

AIMS

The United Kingdom (UK) Prescribing Safety Assessment (PSA) is a 2-h online assessment of basic competence to prescribe and supervise the use of medicines. It has been undertaken by students and doctors in UK medical and foundation schools for the past decade. This study describes the academic characteristics and performance of the assessment; longitudinal performance of candidates and schools; stakeholder feedback; and surrogate markers of prescribing safety in UK healthcare practice.

METHODS

We reviewed the performance data generated by over 70 000 medical students and 3700 foundation doctors who have participated in the PSA since its inception in 2013. These data were supplemented by Likert scale and free text feedback from candidates and a variety of stakeholder groups. Further data on medication incidents, collected by national reporting systems and the regulatory body, are reported, with permission.

RESULTS

We demonstrate the feasibility, high quality and reliability of an online prescribing assessment, uniquely providing a measure of prescribing competence against a national standard. Over 90% of candidates pass the PSA on their first attempt, while a minority are identified for further training and assessment. The pass rate shows some variation between different institutions and between undergraduate and foundation cohorts. Most responders to a national survey agreed that the PSA is a useful instrument for assessing prescribing competence, and an independent review has recommended adding the PSA to the Medical Licensing Assessment. Surrogate markers suggest there has been improvement in prescribing safety in practice, temporally associated with the introduction of the PSA but other factors could be influential too.

CONCLUSIONS

The PSA is a practical and cost-effective way of delivering a reliable national assessment of prescribing competence that has educational impact and is supported by the majority of stakeholders. There is a need to develop national systems to identify and report prescribing errors and the harm they cause, enabling the impact of educational interventions to be measured.

Striking fear into students' hearts: Unforeseen consequences of prescribing education

PURPOSE

Undergraduate medical education (UGME) has to prepare students to do safety-critical work (notably, to prescribe) immediately after qualifying. Despite hospitals depending on them, medical graduates consistently report feeling unprepared to prescribe and they sometimes harm patients. Research clarifying how to prepare students better could improve healthcare safety. Our aim was to explore how students experienced preparing for one of their commonest prescribing tasks: intravenous fluid therapy (IVFT).

METHODS

Complexity assumptions guided the research, which used a qualitative methodology oriented towards hermeneutic phenomenology. The study design was an uncontrolled and unplanned complex intervention: judicial review of the iatrogenic death of five children due to hyponatraemia in our region had resulted in the recommendation that students' education in 'the implementation of important clinical guidelines' relevant to fluid and electrolyte balance should be intensified. An opportunity sample of 40 final-year medical students drew and gave audio-recorded commentaries on rich pictures. We completed two template analyses: one of participants' transcribed commentaries on the pictures and one using a novel heuristic to analyse the pictures themselves. We then reconciled the two analyses into a single template.

RESULTS

There were four themes: affects, teaching and learning, contradictions, and the curriculum as a journey. To explore interconnections between themes, we chose the picture best exemplifying each of the four themes and interpreted the curriculum journey depicted in each of them. These interpretations were grounded in each participant's picture, verbal account of the picture, and the aggregate findings of the template analysis. Participants' experiences were influenced by the situated complexity of IVFT. Layered on top of that, contradictions, overlaps, and gaps within the curriculum introduced extraneous complexity. Confusion and apprehension resulted.

CONCLUSIONS

After spending five years preparing to prescribe IVFT, participants felt unprepared to do so. We conclude that intensive teaching had not achieved its avowed goal of improving students' preparedness for safe practice. Merton's seminal work on the 'unanticipated consequences of purposive social action' suggests that intensive teaching may even have contributed to their unpreparedness.

Evaluation of Dose Adjustment in Patients With Renal Impairment at Muhimbili National Hospital in Tanzania

Background: The burden of renal diseases is increasing in developing countries like Tanzania. Drug accumulation exposes patients with renal impairment to drug toxicity that may lead to adverse drug reactions, poor adherence to treatment, and increased healthcare costs. There is limited information on the appropriateness of dosage regimen adjustment for patients with renal impairment, particularly in developing countries such as Tanzania. This study aimed to investigate the appropriateness of drug dosing in hospitalized patients with renal impairment in Tanzania. Methods: This was a retrospective cross-sectional study. It was conducted between November 2019 and April 2020 amongst hospitalized patients at Muhimbili National Hospital. All enrolled patients had serum creatinine levels ≥1.2 mg/dL and taking at least one drug requiring dosage regimen adjustment. Creatinine clearance was calculated from patient serum creatinine using the Cockcroft-Gault equation. Drug dosing appropriateness was determined by comparing the current practice with tertiary references. The relationship between the patient's baseline characteristics and the rate of dosage regimen adjustment was determined using the X2 test. Univariate and multivariate logistic regression analysis evaluated the predictors of dosing adjustment. Results: Most of the enrolled patients, 269 (98.9%) had comorbidities. Of the medication orders included in the final analysis, 372 (27%) needed dosage regimen adjustment. Out of the 372 medication orders, not adjusted were 168 (45.2%), inappropriately adjusted 105 (28.2%), and appropriately adjusted were only 99 (26.6%). In this study, 212 (77.9%) patients received at least one drug with an incorrect dosage regimen. Females and those with level 4 renal impairment patients were more likely to have their doses appropriately adjusted compared to their counterparts. Conclusions: In this study, about three-quarters of the patients received at least one drug with an incorrect dosage regimen. Thus, appropriate measures such as the availability of national guidelines and clinical decision support systems for drug dosing adjustment in patients' renal impairment should be in place.

Therapeutic inertia

Therapeutic inertia, sometimes referred to as clinical inertia, has been defined as failure to initiate or intensify therapy when therapeutic goals are not reached. Lack of initiation or intensification of treatment according to clinical guidelines has been linked to suboptimal control of a range of chronic conditions. Clinician factors contributing to therapeutic inertia include knowledge gaps; discomfort with uncertainty about the diagnosis, therapeutic target, or evidence; concerns about the safety of treatment intensification; and time constraints. Patient characteristics that may be associated with therapeutic inertia include male sex, older age, lower life expectancy, multiple comorbidities and clinical parameters that are close to target. There may be reasons other than therapeutic inertia that explain apparent undertreatment. Apparent inertia in prescribing may be accompanied by appropriate actions, such as provision of lifestyle advice or interventions to promote adherence to existing medication. Some patients choose not to intensify treatment. Interventions to reduce therapeutic inertia include access to evidence-based treatment guidelines and point-of-care tools, preferably integrated with clinical record systems; clinician education including educational visits; reminders; clinical audits with feedback and reflection on practice; shared decision-making; prompting by patients; and ambulatory or home monitoring (e.g. ambulatory blood pressure monitoring).

What happens when private general practitioners receive incentivisation offers from pharmaceutical sales representatives? A qualitative study in Pakistan

OBJECTIVES

Pharmaceutical incentivisation of physicians for profit maximisation is a well-documented health system challenge. This study examined general practitioners' (GPs) reactions to pharmaceutical incentivisation offers in one region in Pakistan.

METHODS

We used the Standardised Pharmaceutical Sales Representative (SPSR) method and qualitative interviews with GPs. SPSRs were field researchers representing mock pharmaceutical companies who recorded their observations of 267 GPs' responses to pharmaceutical incentivisation offers. We triangulated SPSR data using qualitative interviews with a subset of the same GPs to gather information about how they interpreted different interaction outcomes.

RESULTS

We found four major outcomes for GPs being offered incentives by pharmaceutical companies for prescribing medications. GPs might agree to make incentivisation deals, reject incentivisation offers, disallow PSRs to access them, or remain indeterminate with no clear indication of acceptance or rejection of incentivisation offers. GPs rejecting SPSRs' incentivisation offers indicated having active commitments to other pharmaceutical companies, not being able to work with unheard-of companies, and asking SPSRs to return later.

CONCLUSIONS

The GP-pharmaceutical sales representative interaction that centres on profit-maximisation is complex as offers to engage in prescribing for mutual financial benefit are not taken up immediately. The SPSR method helps understand the extent of distortion of practices impacted by incentivisation. Such an understanding can support the development of strategies to control unethical behaviours.

Trends in medication use at the onset of and during the COVID-19 pandemic in the Republic of Ireland: An interrupted time series study

The COVID-19 pandemic had a substantial impact on healthcare delivery, particularly in general practice. This study aimed to evaluate how dispensing of medications in primary care in Ireland changed following the COVID-19 pandemic's onset compared to expected trends. This interrupted time series study used data on medications prescribed in general practice 2016-2022 to patient eligible for state health cover, approximately one third of the population. Dispensing volumes for all therapeutic subgroups (ATC2 codes) and commonly dispensed medications were summarized. Pre-pandemic data were used to forecast expected trends (with 99% prediction intervals) using the Holt-Winters method, and these were compared to observed dispensing from March 2020 onwards. Many (31/77) therapeutic subgroups had dispensing significantly different from forecast in March 2020. Drugs for obstructive airway disease had the largest difference, with dispensing 26.2% (99%CI 19.5%-33.6%) higher than forecasted. Only two subgroups were significantly lower than forecasted, other gynaecologicals (17.7% lower, 99%CI 6.3%-26.6%) and dressings (11.6%, 99%CI 9.4%-41.6%). Dispensing of amoxicillin products and oral prednisolone were lower than forecasted in the months following the pandemic's onset, particularly during winter 2020/2021. There was a spike in dispensing for many long-term medications in March 2020, while pandemic restrictions likely contributed to reductions for other medications.

Prevalence and Cost of Antipsychotic Prescribing, within the Context of Psycholeptic Prescribing, in the Irish Setting

Psycholeptic and specifically antipsychotic prescribing is increasing worldwide each year. This study aims to investigate the prevalence and cost of antipsychotic prescribing, within the wider frame of psycholeptic prescribing, in the Irish context. Quantitative analysis of a dataset from the Primary Care Reimbursement Service relating to cost and prescribing frequency of ATC Class N05 psycholeptic drugs from January 2020-August 2022 inclusive was conducted using Microsoft® Excel® for Microsoft 365 MSO (Version 2311) and STATA 18. Descriptive statistics and time-trend regression analysis were used to investigate the prescribing prevalence of psycholeptics and antipsychotics licensed for use in the Republic of Ireland, and the total cost per funding scheme. The prevalence of psycholeptic prescribing increased yearly from 2020-2022, peaking at 328,572 prescriptions in December 2020 with a total cost of psycholeptic drugs to the State in 2021 of €57,886,250, which was 0.5% of an increase on 2020. Over the 32-month time period, the average monthly cost of psycholeptic drugs was €4,436,469 on the General Medical Services (GMS) scheme and €369,154 on the Drug Payment Scheme (DPS). In 2021, quetiapine, olanzapine, and risperidone were the most prescribed antipsychotics, accounting for 66.58% of antipsychotics prescribed on the GMS scheme. This study identified the large expenditure on psycholeptics and antipsychotics in Ireland, with a higher proportion of the Irish healthcare budget spent on antipsychotics than that of the UK and the USA. The development of Irish antipsychotic prescribing guidelines may allow for structured, cost-effective prescribing.

Polypharmacy and Deprescribing in Older Adults

Older adults commonly end up on many medications. Deprescribing is an important part of individualizing care for older adults. It is an opportunity to discuss treatment options and revisit medications that may not have been reassessed in many years. A large evidence base exists in the field, suggesting that deprescribing is feasible and safe, though questions remain about the potential clinical benefits. Deprescribing research faces a myriad of challenges, such as identifying and employing the optimal outcome measures. Further, there is uncertainty about which deprescribing approaches are likely to be most effective and in what contexts. Evidence on barriers and facilitators to deprescribing has underscored how deprescribing in routine clinical practice can be complex and challenging. Thus, finding practical, sustainable ways to implement deprescribing is a priority for future research in the field.

Supporting shared decision-making in medicines use with people living with dementia and their carers

Polypharmacy and inappropriate prescribing of psychotropic medicines are common among people living with dementia and pose considerable health risks. One way of addressing these issues is by involving the person and their carer in shared decision-making. This article discusses some of the issues related to polypharmacy and inappropriate prescribing in people living with dementia and examines the concept of shared decision-making in this context. The author details some practical aids that nurses and other healthcare professionals can use to engage people living with dementia and their carers in shared decision-making about medicines use.

Association between Prescribing and Intoxication Rates for Selected Psychotropic Drugs: A Longitudinal Observational Study

Psychotropic prescription drugs are commonly involved in intoxication events. The study's aim was to determine a comparative risk for intoxication in relation to prescribing rates for individual drugs. This was a nationwide observational study in Slovenian adults between 2015 and 2021. Intoxication events with psychotropic drugs were collected from the National Register of intoxications. Dispensing data, expressed in defined daily doses, were provided by the Health Insurance Institute of Slovenia. Intoxication/prescribing ratio values were calculated. The correlation between trends in prescribing and intoxication rates was assessed using the Pearson correlation coefficient. In total, 2640 intoxication cases with psychotropic prescription drugs were registered. Anxiolytics and antipsychotics were the predominant groups. Midazolam, chlormethiazole, clonazepam, sulpiride, and quetiapine demonstrated the highest risk of intoxication, while all antidepressants had a risk several times lower. The best trend correlation was found for the prescribing period of 2 years before the intoxication events. An increase of 1,000,000 defined daily doses prescribed resulted in an increase of fifty intoxication events for antipsychotics, twenty events for antiepileptics, and five events for antidepressants. Intoxication/prescribing ratio calculation allowed for a quantitative comparison of the risk for intoxication in relation to the prescribing rates for psychotropic drugs, providing additional understanding of their toxicoepidemiology.

Ocular therapeutics and the profession of optometry in South Africa

BACKGROUND

 The role of an optometrist as defined by the World Council of Optometry includes the management of ocular diseases. In 2015, the scope of optometry in South Africa was expanded to include ocular therapeutic drugs. To date approximately 27 optometrists have obtained full certification to exercise ocular therapeutic privileges.

AIM

 This study aimed to determine the interest, readiness, as well as challenges, of optometrists for the inclusion of ocular therapeutics into daily practice.

SETTING

 The study was set in South Africa.

METHODS

 A descriptive, cross-sectional study design was employed. Convenience sampling was used to recruit 420 participants from a study population of optometrists registered with the Health Professions Council of South Africa, with data collected using an online questionnaire hosted on social media platforms and distributed by professional organisations. Data were analysed using the Statistical Package for Social Science version 27.

RESULTS

 The majority of respondents (73.3%) reported keenness for ocular therapeutics certification. While 75.7% of respondents had obtained diagnostics certification, only 9.5% were registered with the Health Professions Council of South Africa (HPCSA) with ocular therapeutics certification. Most (92.1%) respondents reported the required minimum of 600 h of clinical training as a major challenge to obtaining ocular therapeutics certification. Almost all (96.9%) of the respondents agreed that ocular therapeutics certification will improve provision of optimal eyecare.

CONCLUSION

 South African optometrists support and are personally interested in ocular therapeutics certification. However, while there is a preponderance of diagnostically qualified optometrists, very few are certified for ocular therapeutics with completion of the required clinical training for certification perceived as the greatest challenge.Contribution: This findings in this study highlight that, current requirements to support ocular therapeutics certification of South African optometrists should be reviewed to ensure an enabling environment for the completion of the clinical training.

Incomplete capture of apremilast in Clinical Practice Research Datalink Aurum: An example of exposure misclassification of specialty treatments in United Kingdom general practice databases

PURPOSE

Nearly all apremilast users captured in Clinical Practice Research Datalink (CPRD) Aurum have only one prescription, which is inconsistent with its prescribing pattern. The goal of this study was to assess capture of apremilast prescriptions in CPRD Aurum by comparison to CPRD GOLD and general practitioner (GP) questionnaires.

METHODS

We compared the number of apremilast prescriptions for patients in Aurum to (1) those in GOLD and (2) those reported by the GPs via questionnaire responses.

RESULTS

There were 441 Aurum patients with an apremilast prescription (424 [96%] in England) and 341 GOLD patients (11 [3%]) in England). In Aurum 91% of all patients (and 96% of English patients) had only one apremilast prescription while in GOLD 29% of all patients (and 82% of English patients) had only one prescription. We received questionnaire responses from GPs for 50 of 390 (13%) patients participating in Aurum who had 57 total apremilast exposed months captured in Aurum. GPs reported 8 (16%) patients with only one prescription and a median of 4 (range 1-35) apremilast prescriptions per patient, yielding 463 total months of apremilast exposure.

CONCLUSIONS

CPRD Aurum captures only one apremilast prescription for most recorded users, though questionnaire responses indicated most patients received multiple prescriptions. Researchers using any UK GP database should be aware of potential for significant exposure misclassification of apremilast and other treatments classified as specialist or shared care by local Area Prescribing Committees.

Prescribing of antivirals for COVID-19 in a South Australian local health network according to statewide guidelines

Antiviral drugs were rapidly implemented into clinical practice for the treatment of high-risk patients with COVID-19, prompting the development of statewide guidelines. This South-Australian study reviewed guideline adherence, assessed prescribing patterns and highlighted the inappropriate management of relative drug-drug interactions and dosing for renal function. Additionally, it evaluated the impact of inappropriate antiviral drug use and suggested methods to improve quality use of medicines.

Tools and guidelines to assess the appropriateness of medication and aid deprescribing: An umbrella review

AIMS

The aim of this umbrella review was to identify tools and guidelines to aid the deprescribing process of potentially inappropriate medications (PIMs), evaluate development and validation methods, and describe evidence levels for medication inclusion.

METHODS

Searches were conducted on MEDLINE (Ovid), Embase.com, Cochrane CDSR, CINAHL (EBSCO), Web of Science Core Collection and guideline databases from the date of inception to 7 July 2022. Following the initial search, an additional search was conducted to identify an updated versions of tools on 17 July 2023. We analysed the contents of tools and guidelines.

RESULTS

From 23 systematic reviews and guidelines, we identified 95 tools (72 explicit, 12 mixed and 11 implicit) and nine guidelines. Most tools (83.2%) were developed to use for older persons, including 14 for those with limited life expectancy. Seven tools were for children <18 years (7.37%). Most explicit/mixed tools (78.57%) and all guidelines were validated. We found 484 PIMs and 202 medications with different appropriateness independent of disease for older persons with normal and limited life expectancy, respectively. Only two tools and eight guidelines reported the evidence level, and a quarter of medications had high-quality evidence.

CONCLUSIONS

Tools are available for a diversity of populations. There were discrepancies, with the same medication being classified as inappropriate in some tools and appropriate in others, possibly due to low-quality evidence. In particular, tools for patients with limited life expectancy were developed based on very limited evidence, and research to generate this evidence is urgently needed. Our medication lists, along with the level of evidence, could facilitate efforts to strengthen the evidence.

Prescribing patterns of adjunctive therapy for the treatment of type 1 diabetes mellitus among Australian endocrinologists

BACKGROUND

Many people living with type 1 diabetes (type 1 diabetes mellitus (T1DM)) do not meet glycaemic targets. Adjunctive therapies have both risks and metabolic benefits and may have a role in selected patients.

AIM

To review the prescribing patterns of adjunctive therapy for the treatment of T1DM diabetes in Australia.

METHODS

We conducted an online survey of Australian endocrinologists and endocrinology registrars. We surveyed the frequency of, motivations and concerns regarding the prescription of metformin, dipeptidyl peptidase-4 (DPP-IV) inhibitors, sodium-glucose transport protein 2 (SGLT-2) inhibitors and glucagon-like peptide 1 receptor agonist (GLP1RA) in T1DM.

RESULTS

Fifty-two practitioners participated. Most respondents (94%) had prescribed adjuncts for the treatment of T1DM in some form. Weight (89%), large insulin doses (73%), glycaemic variability (52%), high HbA1c (48%) and the presence of cardiovascular disease (48%) were the most common factors determining the use of adjuncts. The most commonly prescribed adjuncts were metformin (94%) and SGLT-2 inhibitors (65%). Respondents who had never prescribed an SGLT-2 inhibitor (n = 18) reported risk of diabetic ketoacidosis (DKA) (100%), off-label status (39%), lack of evidence (39%), withdrawal of support from the European Medicines Agency (17%) and cost (17%) as factors contributing to their decision. Thirty-one respondents (60%) had prescribed a GLP1RA. Among those who had never prescribed a GLP1RA (n = 21), off-label status (57%), lack of evidence (48%), cost (38%) and expected lack of efficacy (14%) were factors affecting their decision. Only five respondents (10%) had prescribed a DPP-IV inhibitor.

CONCLUSION

Australian endocrinologists commonly prescribe adjuncts to address cardiometabolic concerns in T1DM. DKA risk and off-label status are significant factors contributing to reluctance to prescribe.

Audit and feedback interventions involving pharmacists to influence prescribing behaviour in general practice: a systematic review and meta-analysis

INTRODUCTION

Pharmacists, as experts in medicines, are increasingly employed in general practices and undertake a range of responsibilities. Audit and feedback (A&F) interventions are effective in achieving behaviour change, including prescribing. The extent of pharmacist involvement in A&F interventions to influence prescribing is unknown. This review aimed to assess the effectiveness of A&F interventions involving pharmacists on prescribing in general practice compared with no A&F/usual care and to describe features of A&F interventions and pharmacist characteristics.

METHODS

Electronic databases (MEDLINE, EMBASE, CINAHL, Cochrane Central Register of Controlled Trials, (Social) Science Citation Indexes, ISI Web of Science) were searched (2012, 2019, 2020). Cochrane systematic review methods were applied to trial identification, selection, and risk of bias. Results were summarized descriptively and heterogeneity was assessed. A random-effects meta-analysis was conducted where studies were sufficiently homogenous in design and outcome.

RESULTS

Eleven cluster-randomized studies from 9 countries were included. Risk of bias across most domains was low. Interventions focussed on older patients, specific clinical area(s), or specific medications. Meta-analysis of 6 studies showed improved prescribing outcomes (pooled risk ratio: 0.78, 95% confidence interval: 0.64-0.94). Interventions including both verbal and written feedback or computerized decision support for prescribers were more effective. Pharmacists who received study-specific training, provided ongoing support to prescribers or reviewed prescribing for individual patients, contributed to more effective interventions.

CONCLUSIONS

A&F interventions involving pharmacists can lead to small improvements in evidence-based prescribing in general practice settings. Future implementation of A&F within general practice should compare different ways of involving pharmacists to determine how to optimize effectiveness.PRISMA-compliant abstract included in Supplementary Material 1.

Prescribing practices of oncology pharmacists working in ambulatory cancer centers in Alberta

OBJECTIVE

To describe and quantify independent prescribing of oncology pharmacists working in adult, ambulatory cancer centers in Alberta, Canada.

METHODS

A retrospective chart review of oncology pharmacists prescribing in the electronic health record, ARIA® was conducted. Prescriptions from January 1, 2018 to June 30, 2018 were analyzed. Descriptive statistics were used to quantify prescription volume and class of medications prescribed. A cross-sectional analysis was then performed on a random sample to determine the type of prescription intervention and evaluate pharmacist documentation.

RESULTS

Over 6 months, 3474 prescriptions were ordered by 33 clinically deployed pharmacists. The median number of medications prescribed was 7 per month (interquartile range: 1.50-27.00; Range: 0.17-79.5). When prescribing was standardized by pharmacist's time clinically deployed, the median was 21.67 (interquartile range: 5.00-79.67; range: 0.67-216.67) prescriptions per month per full-time equivalent. The most prescribed class of medication was antiemetic (24.1%). From a sample of 346 prescriptions, 172 (50%) were new medications initiated, 160 (46%) were the continuation of existing prescriptions and 14 (4%) were prescription dosage adjustments. Adherence to the specified documentation standards was 47%.

CONCLUSIONS

Oncology pharmacists utilize their independent prescribing to initiate and continue supportive care medications for cancer patients. The prescribing volume varied greatly among pharmacists. Opportunities exist to further engage pharmacist prescribing.

Impact of sociodemographic status and UTI symptoms on women's health-care seeking and management in England: findings from an e-survey conducted during the first year of the COVID-19 pandemic

BACKGROUND

Multiple factors may influence women's experiences of urinary tract infection (UTI) and its clinical management.

AIM

To explore how women's background, symptoms, and severity of symptoms influence UTI reporting and management.

DESIGN & SETTING

Internet questionnaire targeting women in England, focusing on UTI symptoms, care seeking, and management.

METHOD

A total of 1096 women aged ≥16 years with UTI symptoms in the previous year completed the questionnaire in March and April 2021. Multivariable logistic regression was ued to estimate the odds of relevant outcomes while adjusting for background characteristics.

RESULTS

Women with children in their household, who were aged under 45 years, or who were married or cohabitating were more likely to experience UTI symptoms. The odds of antibiotic prescribing were lower if women reported dysuria (adjusted odds ratio [AOR] = 0.65, 95% confidence interval [CI] = 0.49 to 0.85), frequency (AOR = 0.63, 95% CI = 0.48 to 0.83), or vaginal discharge (AOR = 0.69, 95% CI = 0.50 to 0.96), but higher if reporting haematuria (AOR = 2.81, 95% CI = 1.79 to 4.41), confusion (AOR = 2.14, 95% CI = 1.16 to 3.94), abdominal pain (AOR = 1.35, 95% CI = 1.04 to 1.74), or systemic symptoms (AOR = 2.04, 95% CI = 1.56 to 2.69). Those with abdominal pain or two or more of nocturia, dysuria, or cloudy urine had lower odds of receiving a delayed antibiotic, while those with incontinence, confusion, unsteadiness, or low temperature had higher odds of a delayed prescription. Increasing symptom severity was associated with greater odds of receiving antibiotics.

CONCLUSION

Except for reduced prescribing if a woman had dysuria and frequency, antibiotic prescribing followed an expected pattern, aligning generally with national guidance. Symptom severity and the likelihood of systemic infection probably influenced care seeking and prescribing. Sexual intercourse and childbirth may be key times to target women with messages about UTI prevention.

Evaluating the UK's first national prescribing assessment for GPs in training using an online survey

BACKGROUND

GP trainees may not have experienced a systematic and comprehensive education in safe prescribing. Therefore, a self-assessment prescribing review was developed.

AIM

To determine whether the assessment was feasible, had face validity, and did not disadvantage particular groups of participants.

DESIGN & SETTING

An online survey that evaluates the opinions of GPs in training of a prescribing assessment in the UK. All full-time UK trainees who started their final year of GP training in August 2019 undertook the prescribing assessment along with their trainers, after which they completed an online anonymous feedback questionnaire.

METHOD

The questionnaire completed by trainees sought their opinions of the assessment, and collected ethnicity and disability data. The trainer questionnaire was similar but did not include any demographic information.

RESULTS

The questionnaire was completed by 1741 trainees and 1576 trainers. There was no evidence that ethnic group and disability were related to aspects of the review. Most of the trainees (76.4%, n = 1330) and trainers (82.0%, n = 1293) agreed or strongly agreed that the prescribing review was helpful for assessing and learning about the trainee's prescribing. However, most participants (63.2%, n = 1092) took >4 hours to review their prescriptions. A majority of trainees (90.2%, n = 1571) reported that completing the assessment had resulted in a change in their prescribing practice.

CONCLUSION

The majority of trainers and trainees reported that the prescribing assessment was helpful. The study was not able to assess whether there had been an actual change in practice that resulted in an error reduction.