Decrease in use of contraindicated drugs with automated alerts in children

Use of interrupted time series methods in the evaluation of health system quality improvement interventions: a methodological systematic review

BACKGROUND

When randomisation is not possible, interrupted time series (ITS) design has increasingly been advocated as a more robust design to evaluating health system quality improvement (QI) interventions given its ability to control for common biases in healthcare QI. However, there is a potential risk of producing misleading results when this rather robust design is not used appropriately. We performed a methodological systematic review of the literature to investigate the extent to which the use of ITS has followed best practice standards and recommendations in the evaluation of QI interventions.

METHODS

We searched multiple databases from inception to June 2018 to identify QI intervention studies that were evaluated using ITS. There was no restriction on date, language and participants. Data were synthesised narratively using appropriate descriptive statistics. The risk of bias for ITS studies was assessed using the Cochrane Effective Practice and Organisation of Care standard criteria. The systematic review protocol was registered in PROSPERO (registration number: CRD42018094427).

RESULTS

Of 4061 potential studies and 2028 unique records screened for inclusion, 120 eligible studies assessed eight QI strategies and were from 25 countries. Most studies were published since 2010 (86.7%), reported data using monthly interval (71.4%), used ITS without a control (81%) and modelled data using segmented regression (62.5%). Autocorrelation was considered in 55% of studies, seasonality in 20.8% and non-stationarity in 8.3%. Only 49.2% of studies specified the ITS impact model. The risk of bias was high or very high in 72.5% of included studies and did not change significantly over time.

CONCLUSIONS

The use of ITS in the evaluation of health system QI interventions has increased considerably over the past decade. However, variations in methodological considerations and reporting of ITS in QI remain a concern, warranting a need to develop and reinforce formal reporting guidelines to improve its application in the evaluation of health system QI interventions.

Effect of providing drug utilization review information on tricyclic antidepressant prescription in the elderly

Tricyclic antidepressants are known as potentially inappropriate medications in the elderly. A notification issued in July 2015 in South Korea recommended caution while prescribing tricyclic antidepressants to the elderly. Further, since October 2015, the nationwide computerized drug utilization review monitoring system provides a pop-up window, on a real-time basis, whenever tricyclic antidepressants are prescribed to elderly outpatients. Therefore, we evaluated whether providing drug utilization review information was effective in reducing tricyclic antidepressant prescription to elderly outpatients. We used the Health Insurance Review and Assessment Service-Adult Patient Sample data from 2014 to 2016. Data related to the prescription of tricyclic antidepressants to outpatients aged 65 years or more were extracted. We determined the number of prescriptions per day per 100,000 elderly patients in each month, compared the average number of prescriptions before and after the drug utilization review information was provided, and evaluated the changes in the number of prescriptions by using an interrupted time series analysis. The average number of tricyclic antidepressant prescriptions per day per 100,000 elderly patients decreased from 76.6 (75.5 to 77.6) to 65.7 (64.5 to 66.9), a 14.2% reduction after the provision of drug utilization review information started. Following initiation of provision of drug utilization review information, there was an immediate drop of 9.2 tricyclic antidepressant prescriptions per day per 100,000 elderly patients, whereas there was no statistically significant change in trends. Providing the drug utilization review information on tricyclic antidepressant prescription for the elderly contributed to the reduction in tricyclic antidepressant prescriptions.

Increased use of third-generation cephalosporin antibiotics in the outpatient setting in Korean children and adolescents

BACKGROUND

Antimicrobial resistance is a concern to public health, and controlling antibiotic use is therefore important. This study analyzed the trend in outpatient antibiotic prescriptions in children and adolescents in Korea.

METHODS

Using National Prescribing Sample data from the Korea Health Insurance Review and Assessment Service between 1 January 2010 and 31 December 2014, we analyzed outpatient systemic antibiotic (anatomical therapeutic chemical [ATC] J01) prescriptions in patients aged 2-17 years. The antibiotic rate was defined as the proportion of all outpatient prescriptions for antibiotics. We calculated absolute and relative differences with 95%CI between 2010 and 2014 in the antibiotic rate by age group (2-6, 7-11, and 12-17 years) and the percentage of antibiotic prescriptions by antibiotic class. Seven of the most commonly used antibiotic drugs were identified based on defined daily dose.

RESULTS

A total of 7 261 176 prescriptions were written for 1 039 756 pediatric patients between 2010 and 2014. The antibiotic rate in all patients increased from 34.8% in 2010 to 70.4% in 2014, resulting in the relative difference of 102.1% (95%CI: 101.7-102.5). Extended spectrum penicillins were the most commonly prescribed antibiotic class, accounting for 40.0-41.0% of all antibiotic prescriptions. The use of third-generation cephalosporins increased steeply with the relative difference of 55.7% (95%CI: 55.2-56.2). Amoxicillin/clavulanate, an extended spectrum antibiotic drug, was the predominately used antibiotic drug but the use of cefpodoxime, a third-generation cephalosporin, increased by 96%.

CONCLUSIONS

The use of outpatient antibiotics, especially third-generation cephalosporins, has increased in children and adolescents in Korea.

Evaluation of preventable adverse drug reactions by implementation of the nationwide network of prospective drug utilization review program in Korea

BACKGROUND

A prospective Drug Utilization Review (DUR) program has been implemented in Korea to improve the quality and safety of medication use.

OBJECTIVE

To evaluate the influence of the DUR program in reducing incidence of preventable adverse drug reactions (pADRs).

METHODS

This study was performed using administrative data from the Health Insurance Review and Assessment Service (HIRA). The claims data for all adult patients with adverse drug events (ADE)-related diagnoses from 2009 to 2014 were obtained. Incidence rates of first-time and repeat pADRs prior to and after DUR program implementation were evaluated. Quarterly trends in incidence rates of overall ADE, allergic reactions, and ADRs were analyzed.

RESULTS

Data extraction covering the period from 2009 to 2014 led to the identification of 3,927,662 records. First-time pADR rates decreased gradually after implementation of the DUR program (change in slope: -0.016, p = 0.02). The program had a similar influence on repeat pADR rates (change in slope: -0.006, p≤0.01). The program did not decrease rates of first-time or repeat allergic reactions (change in slope: 0.018, p = 0.07 and 0.003, p = 0.04, respectively). In the cohort aged ≤65 years, first-time pADR rate reduction was significant (28.2% [27.1-29.3] in ≤18 years, and 19.8% [18.1-21.5] in 19-64 years). In contrast, first-time pADR rate was increased by 0.6% [-0.7-1.9] in patients ≥65 years.

CONCLUSION

Implementation of the prospective DUR program effectively reduced the number of pADRs. In the future, to reduce non-preventable ADRs such as allergic reactions, provision of clinical information including allergy history should be added to the DUR program.