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Platen M, Flessa S, Teipel S, Rädke A, Scharf A, Mohr W, Buchholz M, Hoffmann W, Michalowsky B. Impact of low-value medications on quality of life, hospitalization and costs - A longitudinal analysis of patients living with dementia. Alzheimers Dement 2023; 19:4520-4531. [PMID: 36905286 DOI: 10.1002/alz.13012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Revised: 01/19/2023] [Accepted: 01/22/2023] [Indexed: 03/12/2023]
Abstract
INTRODUCTION This study aimed to analyze the impact of low-value medications (Lvm), that is, medications unlikely to benefit patients but to cause harm, on patient-centered outcomes over 24 months. METHODS This longitudinal analysis was based on baseline, 12 and 24 months follow-up data of 352 patients with dementia. The impact of Lvm on health-related quality of life (HRQoL), hospitalizations, and health care costs were assessed using multiple panel-specific regression models. RESULTS Over 24 months, 182 patients (52%) received Lvm at least once and 56 (16%) continuously. Lvm significantly increased the risk of hospitalization by 49% (odds ratio, confidence interval [CI] 95% 1.06-2.09; p = 0.022), increased health care costs by €6810 (CI 95% -707€-14,27€; p = 0.076), and reduced patients' HRQoL (b = -1.55; CI 95% -2.76 to -0.35; p = 0.011). DISCUSSION More than every second patient received Lvm, negatively impacting patient-reported HRQoL, hospitalizations, and costs. Innovative approaches are needed to encourage prescribers to avoid and replace Lvm in dementia care. HIGHLIGHTS Over 24 months, more than every second patient received low-value medications (Lvm). Lvm negatively impact physical, psychological, and financial outcomes. Appropriate measures are needed to change prescription behaviors.
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Affiliation(s)
- Moritz Platen
- German Center for Neurodegenerative Diseases (DZNE), site Greifswald, Ellernholzstrasse 1-2, Greifswald, Germany
| | - Steffen Flessa
- Department of General Business Administration and Health Care Management, University of Greifswald, Friedrich-Loeffler-Straße 70, Greifswald, Germany
| | - Stefan Teipel
- German Center for Neurodegenerative Diseases (DZNE), site Rostock, Gehlsheimer Str. 20, Rostock, Germany
- Department of Psychosomatic Medicine, University Hospital Rostock, Gehlsheimer Str. 20, Rostock, Germany
| | - Anika Rädke
- German Center for Neurodegenerative Diseases (DZNE), site Greifswald, Ellernholzstrasse 1-2, Greifswald, Germany
| | - Annelie Scharf
- German Center for Neurodegenerative Diseases (DZNE), site Greifswald, Ellernholzstrasse 1-2, Greifswald, Germany
| | - Wiebke Mohr
- German Center for Neurodegenerative Diseases (DZNE), site Greifswald, Ellernholzstrasse 1-2, Greifswald, Germany
| | - Maresa Buchholz
- German Center for Neurodegenerative Diseases (DZNE), site Greifswald, Ellernholzstrasse 1-2, Greifswald, Germany
| | - Wolfgang Hoffmann
- German Center for Neurodegenerative Diseases (DZNE), site Greifswald, Ellernholzstrasse 1-2, Greifswald, Germany
- Institute for Community Medicine, Section Epidemiology of Health Care and Community Health, University Medicine Greifswald (UMG), Ellernholzstrasse 1-2, Greifswald, Germany
| | - Bernhard Michalowsky
- German Center for Neurodegenerative Diseases (DZNE), site Greifswald, Ellernholzstrasse 1-2, Greifswald, Germany
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Michalowsky B, Platen M, Bohlken J, Kostev K. Association Between Low- and High-Value Medication and Hospital Referrals by General Practitioners in Patients Living with Dementia. J Alzheimers Dis Rep 2022; 6:641-650. [DOI: 10.3233/adr-220004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Accepted: 08/23/2022] [Indexed: 11/15/2022] Open
Abstract
Background: Previous studies revealed that low-value medication (LvM), drugs that provide little or no benefit but have the potential to cause harm, are associated with hospitalizations in dementia. Recommended medications, referred to as high-value medication (HvM), can be used alternately. However, the effect of LvM and HvM on hospitalizations is uncertain. Objective: To determine the prevalence of LvM and HvM in hospitalized and non-hospitalized patients living with dementia (PwD) and the odds for hospital referrals in PwD receiving LvM or HvM. Methods: The analysis was based on 47,446 PwD who visited a general practitioner practice between 2017 and 2019. Different guidelines were used to elicit LvM and HvM, resulting in 185 LvM and HvM related recommendations. Of these, 117 recommendations (83 for LvM, 34 for HvM) were categorized into thirteen therapy classes. The association of hospital referrals issued by general practitioners and receiving LvM or HvM was assessed using multiple logistic regression models. Results: 20.4% of PWD received LvM. Most frequently prescribed LvM were non-recommended sedatives and hypnotics, analgesics, and antidepressants. Recommended HvM were 3.4 (69.9%) more frequently prescribed than LvM. Most commonly prescribed HvM were recommended antihypertensives, antiplatelet agents, and antiarrhythmics. Both receiving LvM and receiving HvM were associated with higher odds for hospital referrals. When receiving LvM were compared to HvM, no significant differences could be found in hospital referrals. Conclusion: LvM is highly prevalent but did not cause more likely hospital referrals than HvM. Further research should focus on acute hospitalizations, not only on planned hospital referrals.
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Affiliation(s)
- Bernhard Michalowsky
- German Center for Neurodegenerative Diseases (DZNE), Site Rostock/Greifswald, Greifswald, Germany
| | - Moritz Platen
- German Center for Neurodegenerative Diseases (DZNE), Site Rostock/Greifswald, Greifswald, Germany
| | - Jens Bohlken
- Institute for Social Medicine, Occupational Medicine, and Public Health (ISAP) of the Medical Faculty, University of Leipzig, Leipzig, Germany
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Pratt N, Camacho X, Vajdic C, Degenhardt L, Laba TL, Hillen J, Etherton-Beer C, Preen D, Jorm L, Donnolley N, Havard A, Pearson SA. The Medicines Intelligence Centre of Research Excellence: Co-creating real-world evidence to support the evidentiary needs of Australian medicines regulators and payers. Int J Popul Data Sci 2022; 6:1726. [PMID: 35784493 PMCID: PMC9208358 DOI: 10.23889/ijpds.v6i1.1726] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Regulators and payers play a pivotal role in facilitating timely and affordable access to safe and efficacious medicines. They use evidence generated from randomised clinical trials (RCTs) to support decisions to register and subsidise medicines. However, at the time of registration and subsidy approval, regulators and payers face uncertainty about how RCT outcomes will translate to real-world clinical practice. In response to this situation, medicines policy agencies worldwide have endorsed the use of real-world data (RWD) to derive novel insights on the use and outcomes of prescribed medicines. Recent reforms around data availability and use in Australia are creating unparalleled data access and opportunities for Australian researchers to undertake large-scale research to generate evidence on the safety and effectiveness of medicines in the real world. Highlighting the critical importance of research in this area, Quality Use of Medicines and Medicine Safety was announced as Australia's 10th National Health Priority in 2019. The National Health and Medical Research Council, Medicines Intelligence Centre of Research Excellence (MI-CRE) has been formed to take advantage of the renewed focus on quality use of medicines and the changing data landscape in Australia. It will generate timely research supporting the evidentiary needs of Australian medicines regulators and payers by accelerating the development and translation of real-world evidence on medicines use and outcomes. MI-CRE is developing a coordinated approach to identify, triage and respond to priority questions where there are significant uncertainties about medicines use, (cost)-effectiveness, and/or safety and creating a data ecosystem that will streamline access to Australian data to enable researchers to generate robust evidence in a timely manner. This paper outlines how MI-CRE will partner with policy makers, clinicians, and consumer advocates to leverage real-world data to co-create real-world evidence, to improve quality use of medicines and reduce medicine-related harm.
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Affiliation(s)
- Nicole Pratt
- Quality Use of Medicines and Pharmacy Research Centre, Clinical and Health Sciences, University of South Australia, Adelaide, SA 5000, Australia,Corresponding author: Nicole Pratt
| | - Ximena Camacho
- Centre for Big Data Research in Health, Faculty of Medicine, UNSW Sydney, NSW 2052, Australia
| | - Claire Vajdic
- Centre for Big Data Research in Health, Faculty of Medicine, UNSW Sydney, NSW 2052, Australia
| | - Louisa Degenhardt
- National Drug and Alcohol Research Centre, Faculty of Medicine, UNSW Sydney, NSW 2052, Australia
| | - Tracey-Lea Laba
- Quality Use of Medicines and Pharmacy Research Centre, Clinical and Health Sciences, University of South Australia, Adelaide, SA 5000, Australia,Centre for Health Economics Research and Evaluation, Faculty of Health, UTS Sydney, NSW 2006, Australia
| | - Jodie Hillen
- Quality Use of Medicines and Pharmacy Research Centre, Clinical and Health Sciences, University of South Australia, Adelaide, SA 5000, Australia
| | - Christopher Etherton-Beer
- WA Centre for Health and Ageing, Medical School, University of Western Australia, Perth, WA 6009, Australia
| | - David Preen
- WA Centre for Health and Ageing, Medical School, University of Western Australia, Perth, WA 6009, Australia
| | - Louisa Jorm
- Centre for Big Data Research in Health, Faculty of Medicine, UNSW Sydney, NSW 2052, Australia
| | - Natasha Donnolley
- Centre for Big Data Research in Health, Faculty of Medicine, UNSW Sydney, NSW 2052, Australia
| | - Alys Havard
- Centre for Big Data Research in Health, Faculty of Medicine, UNSW Sydney, NSW 2052, Australia,National Drug and Alcohol Research Centre, Faculty of Medicine, UNSW Sydney, NSW 2052, Australia
| | - Sallie-Anne Pearson
- Centre for Big Data Research in Health, Faculty of Medicine, UNSW Sydney, NSW 2052, Australia
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Mellor R, Khoo A, Saunders-Dow E, Raguz E, Taing MW, Hanjani LS, Freeman C, Crawford D. Polypharmacy in Australian Veterans with Post-traumatic Stress Disorder upon Admission to a Mental Health Facility: A Retrospective Chart Review. Drugs Real World Outcomes 2022; 9:347-357. [PMID: 35581527 PMCID: PMC9392669 DOI: 10.1007/s40801-022-00298-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/09/2022] [Indexed: 11/14/2022] Open
Abstract
Objective Polypharmacy increases the risk of adverse drug events and drug–drug interactions, and contributes to falls, hospital admissions, morbidity and mortality. Veterans with post-traumatic stress disorder often have psychological and physical comorbidities, increasing the likelihood of general and psychotropic polypharmacy. This study investigates the prevalence of general and psychotropic polypharmacy in inpatient veterans with post-traumatic stress disorder, and illustrates potential risks associated with polypharmacy in this population. Methods Medical records of 219 veterans admitted to a mental health facility for post-traumatic stress disorder management were retrospectively reviewed. Medication lists on admission were extracted and coded according to Anatomical Therapeutic Chemical Classification classes. The prevalence of general (five or more total medications), psychotropic (two or more N-code medications), and sedative (two or more medications with sedating effects) polypharmacy and Drug Burden Index were calculated. Class combinations were reported, and associations between demographic characteristics and polypharmacy were determined. Results Mean age was 62.5 (± 14.6) years. In addition to post-traumatic stress disorder, 90.9% had a diagnosis of at least one other psychiatric condition, and 96.8% had a diagnosis of at least one non-psychiatric medical condition. The prevalence of general polypharmacy was 76.7%, psychotropic polypharmacy was 79.9% and sedative polypharmacy was 75.3%. Drug Burden Index scores ranged from 0 to 8.2, with 66.2% of participants scoring ≥ 1. Conclusions This cohort of inpatient veterans with post-traumatic stress disorder had a high prevalence of general, psychotropic and sedative polypharmacy, and were at high risk for drug-related adverse events. This highlights the importance of increasing awareness of polypharmacy and potentially inappropriate drug combinations, and the need for improved medication review by prescribers. Supplementary Information The online version contains supplementary material available at 10.1007/s40801-022-00298-3.
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Affiliation(s)
- Rebecca Mellor
- Gallipoli Medical Research Foundation, Greenslopes Private Hospital, 121 Newdegate Street, Greenslopes, QLD, 4120, Australia.
| | - Andrew Khoo
- Toowong Private Hospital, Toowong, QLD, Australia
| | - Elise Saunders-Dow
- Gallipoli Medical Research Foundation, Greenslopes Private Hospital, 121 Newdegate Street, Greenslopes, QLD, 4120, Australia
| | - Ella Raguz
- Gallipoli Medical Research Foundation, Greenslopes Private Hospital, 121 Newdegate Street, Greenslopes, QLD, 4120, Australia
| | - Meng-Wong Taing
- Pharmacy Australia Centre of Excellence (PACE), School of Pharmacy, The University of Queensland, Woolloongabba, QLD, Australia
| | - Leila Shafiee Hanjani
- Centre for Health Sciences Research, Faculty of Medicine, The University of Queensland, Princess Alexandra Hospital, Woolloongabba, QLD, Australia
| | - Chris Freeman
- Pharmacy Australia Centre of Excellence (PACE), School of Pharmacy, The University of Queensland, Woolloongabba, QLD, Australia
| | - Darrell Crawford
- Gallipoli Medical Research Foundation, Greenslopes Private Hospital, 121 Newdegate Street, Greenslopes, QLD, 4120, Australia
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Thiruchelvam K, Byles J, Hasan SS, Egan N, Kairuz T. Impact of medication reviews on potentially inappropriate medications and associated costs among older women in aged care. Res Social Adm Pharm 2022; 18:3758-3765. [DOI: 10.1016/j.sapharm.2022.05.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2021] [Revised: 03/04/2022] [Accepted: 05/07/2022] [Indexed: 12/01/2022]
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Associations Between Low-Value Medication in Dementia and Healthcare Costs. Clin Drug Investig 2022; 42:427-437. [PMID: 35482178 PMCID: PMC9106620 DOI: 10.1007/s40261-022-01151-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/07/2022] [Indexed: 11/03/2022]
Abstract
BACKGROUND Low-value medications (Lvm) provide little or no benefit to patients, may be harmful, and waste healthcare resources and costs. Although evidence from the literature indicates that Lvm is highly prevalent in dementia, evidence about the financial consequences of Lvm in dementia is limited. This study analyzed the association between receiving Lvm and healthcare costs from a public payers' perspective. METHODS This analysis is based on data of 516 community-dwelling people living with dementia (PwD). Fourteen Lvm were extracted from dementia-specific guidelines, the German equivalent of the Choosing Wisely campaign, and the PRISCUS list. Healthcare utilization was retrospectively assessed via face-to-face interviews with caregivers and monetarized by standardized unit costs. Associations between Lvm and healthcare costs were analyzed using multiple linear regression models. RESULTS Every third patient (n = 159, 31%) received Lvm. Low-value antiphlogistics, analgesics, anti-dementia drugs, sedatives and hypnotics, and antidepressants alone accounted for 77% of prescribed Lvm. PwD who received Lvm were significantly less cognitively impaired than those not receiving Lvm. Receiving Lvm was associated with higher medical care costs (b = 2959 €; 95% CI 1136-4783; p = 0.001), particularly due to higher hospitalization (b = 1911 €; 95% CI 376-3443; p = 0.015) and medication costs (b = 905 €; 95% CI 454-1357; p < 0.001). CONCLUSION Lvm were prevalent, more likely occurring in the early stages of dementia, and cause financial harm for payers due to higher direct medical care costs. Further research is required to derive measures to prevent cost-driving Lvm in primary care, that is, implementing deprescribing interventions and moving health expenditures towards higher value resource use.
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Cheikh-Moussa K, Caro Mendivelso J, Carrillo I, Astier-Peña MP, Olivera G, Silvestre C, Nuín M, Mira JJ. Frequency and estimated costs of ten low-value practices in the Spanish Primary Care: a retrospective study. Expert Opin Drug Saf 2022; 21:995-1003. [PMID: 35020555 DOI: 10.1080/14740338.2022.2026924] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
BACKGROUND The frequency of low-value practices (LVPs) in the healthcare system is a worldwide challenge. Far less is known about the related extra cost. This study aimed to evaluate the LVPs trend in Spanish primary care (PC), its frequency in both sexes, and estimate its related extra cost. METHODS A multicentric, retrospective, and national research project was conducted. Ten LVPs highly frequent and potentially harmful for patients were analyzed. Algorithms were applied to collect the data from 28,872,851 episodes registered into national databases (2015-2017). Cost estimation was made. RESULTS LVPs registered a total of 7,160,952 (26.5%) episodes plus a total of 259,326 avoidable PSA screening tests. In adults, a high frequency was found for prescription of 1g paracetamol >3 days, antibiotics for acute bronchitis (unconfirmed comorbidity), and benzodiazepines in patients >65 years with insomnia. Women received more jeopardizing practices (p≤0.001). Pediatrics presented a downward of antibiotic and paracetamol-ibuprofen prescription combination. The estimated extra cost was close to €292 million (2.8% of the total cost in PC). CONCLUSION LVPs reduction during the analyzed period was moderate compared to studies following 'Choosing Wisely list' of LVPs and must improve to reduce patient risk and the extra related costs.
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Affiliation(s)
- Kamila Cheikh-Moussa
- Foundation for the Promotion of Health and Biomedical Research of Valencia Region (FISABIO), Sant Joan d'Alacant, Spain
| | - Johanna Caro Mendivelso
- Agency for Health Quality and Assessment of Catalonia (AQuAS), Barcelona, Spain.,CIBER Epidemiology and Public Health (CIBERESP), Barcelona, Spain
| | - Irene Carrillo
- Department of Health Psychology, Miguel Hernández University, Elche, Spain
| | - María Pilar Astier-Peña
- Family and Community Medicine, Universitas Health Centre, Zaragoza I Sector, Aragonese Health Service (SALUD), Zaragoza, Spain.,University of Zaragoza, Aragon Health Research Institute (IISA), Zaragoza, Spain
| | | | - Carmen Silvestre
- Healthcare Effectiveness and Safety Service, Navarre Health Service-Osasunbidea, Pamplona, Spain
| | - Marian Nuín
- Healthcare Effectiveness and Safety Service, Navarre Health Service-Osasunbidea, Pamplona, Spain
| | - José Joaquín Mira
- Department of Health Psychology, Miguel Hernández University, Elche, Spain.,Health District Alicante-Sant Joan, Alicante, Spain.,REDISSEC, Spain
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Platen M, Fleßa S, Rädke A, Wucherer D, Thyrian JR, Mohr W, Scharf A, Mühlichen F, Hoffmann W, Michalowsky B. Prevalence of Low-Value Care and Its Associations with Patient-Centered Outcomes in Dementia. J Alzheimers Dis 2021; 83:1775-1787. [PMID: 34459396 PMCID: PMC8609693 DOI: 10.3233/jad-210439] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Background: Low-value care (LvC) is defined as care unlikely to provide a benefit to the patient regarding the patient’s preferences, potential harms, costs, or available alternatives. Avoiding LvC and promoting recommended evidence-based treatments, referred to as high-value care (HvC), could improve patient-reported outcomes for people living with dementia (PwD). Objective: This study aims to determine the prevalence of LvC and HvC in dementia and the associations of LvC and HvC with patients’ quality of life and hospitalization. Methods: The analysis was based on data of the DelpHi trial and included 516 PwD. Dementia-specific guidelines, the “Choosing Wisely” campaign and the PRISCUS list were used to indicate LvC and HvC treatments, resulting in 347 LvC and HvC related recommendations. Of these, 77 recommendations (51 for LvC, 26 for HvC) were measured within the DelpHi-trial and finally used for this analysis. The association of LvC and HvC treatments with PwD health-related quality of life (HRQoL) and hospitalization was assessed using multiple regression models. Results: LvC was highly prevalent in PwD (31%). PwD receiving LvC had a significantly lower quality of life (b = –0.07; 95% CI –0.14 – –0.01) and were significantly more likely to be hospitalized (OR = 2.06; 95% CI 1.26–3.39). Different HvC treatments were associated with both positive and negative changes in HRQoL. Conclusion: LvC could cause adverse outcomes and should be identified as early as possible and tried to be replaced. Future research should examine innovative models of care or treatment pathways supporting the identification and replacement of LvC in dementia.
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Affiliation(s)
- Moritz Platen
- German Center for Neurodegenerative Diseases (DZNE), site Rostock/Greifswald, Greifswald, Germany
| | - Steffen Fleßa
- Department of General Business Administration and Health Care Management, University of Greifswald, Greifswald, Germany
| | - Anika Rädke
- German Center for Neurodegenerative Diseases (DZNE), site Rostock/Greifswald, Greifswald, Germany
| | - Diana Wucherer
- German Center for Neurodegenerative Diseases (DZNE), site Rostock/Greifswald, Greifswald, Germany
| | - Jochen René Thyrian
- German Center for Neurodegenerative Diseases (DZNE), site Rostock/Greifswald, Greifswald, Germany.,Institute for Community Medicine, Section Epidemiology of Health Care and Community Health, University Medicine Greifswald (UMG), Greifswald, Germany
| | - Wiebke Mohr
- German Center for Neurodegenerative Diseases (DZNE), site Rostock/Greifswald, Greifswald, Germany
| | - Annelie Scharf
- German Center for Neurodegenerative Diseases (DZNE), site Rostock/Greifswald, Greifswald, Germany
| | - Franka Mühlichen
- German Center for Neurodegenerative Diseases (DZNE), site Rostock/Greifswald, Greifswald, Germany
| | - Wolfgang Hoffmann
- German Center for Neurodegenerative Diseases (DZNE), site Rostock/Greifswald, Greifswald, Germany.,Institute for Community Medicine, Section Epidemiology of Health Care and Community Health, University Medicine Greifswald (UMG), Greifswald, Germany
| | - Bernhard Michalowsky
- German Center for Neurodegenerative Diseases (DZNE), site Rostock/Greifswald, Greifswald, Germany
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Duan KI, Spece LJ, Wong ES, Feemster LC, Donovan LM, Griffith MF, Keller TL, Bryant AD, Au DH. Low-Value Inhaled Corticosteroids in Chronic Obstructive Pulmonary Disease and the Association with Healthcare Utilization and Costs. Ann Am Thorac Soc 2021; 18:989-996. [PMID: 33290180 PMCID: PMC8456735 DOI: 10.1513/annalsats.202009-1128oc] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2020] [Accepted: 12/08/2020] [Indexed: 11/20/2022] Open
Abstract
Rationale: Inhaled corticosteroids (ICS) are not first-line therapy for patients with chronic obstructive pulmonary disease (COPD) at low risk of exacerbations, but they are commonly prescribed despite evidence of harm. We consider ICS prescription in this population to be of "low value." The association of low-value ICS with subsequent healthcare utilization and costs is unknown. Understanding this relationship could inform efforts to reduce the delivery of low-value care. Objectives: To determine whether low-value ICS prescribing is associated with higher outpatient healthcare utilization and costs among patients with COPD who are at low risk of exacerbation. Methods: We performed a cohort study between January 1, 2010, and December 31, 2018, identifying a cohort of veterans with COPD who performed pulmonary function tests (PFTs) at 21 Veterans Affairs medical centers nationwide. Patients were defined as having low exacerbation risk if they experienced less than two outpatient exacerbations and no hospital admissions for COPD in the year before PFTs. Our primary exposure was the receipt of an ICS prescription in the 3 months before the date of PFTs. Our primary outcomes were outpatient utilization and outpatient costs in the 1 year after PFTs. For inference, we generated negative binomial models for utilization and generalized linear models for costs, adjusting for confounders. Results: We identified a total of 31,551 patients with COPD who were at low risk of exacerbation. Of these patients, 9,742 were prescribed low-value ICS (mean [standard deviation (SD)] age, 69 [9] yr), and 21,809 were not prescribed low-value ICS (mean [SD] age, 68 [9] yr). Compared with unexposed patients, those exposed to low-value ICS had 0.53 more encounters per patient per year (95% confidence interval CI, 0.23-0.83) and incurred $154.72 higher costs/patient/year (95% CI, $45.58-$263.86). Conclusions: Low-value ICS prescription was associated with higher subsequent outpatient healthcare utilization and costs. Potential mechanisms for the observed association are that 1) low-value ICS may be a marker of poor respiratory symptom control, 2) there is confounding by indication, or 3) low-value ICS results in increased drug costs or utilization. Health systems should identify low-value ICS prescriptions as a target to improve value-based care.
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Affiliation(s)
- Kevin I. Duan
- Health Services Research and Development, Veterans Affairs Puget Sound Health Care System, Seattle, Washington
- Division of Pulmonary, Critical Care, and Sleep Medicine, and
| | - Laura J. Spece
- Health Services Research and Development, Veterans Affairs Puget Sound Health Care System, Seattle, Washington
- Division of Pulmonary, Critical Care, and Sleep Medicine, and
| | - Edwin S. Wong
- Health Services Research and Development, Veterans Affairs Puget Sound Health Care System, Seattle, Washington
- Department of Health Services, University of Washington, Seattle, Washington
| | - Laura C. Feemster
- Health Services Research and Development, Veterans Affairs Puget Sound Health Care System, Seattle, Washington
- Division of Pulmonary, Critical Care, and Sleep Medicine, and
| | - Lucas M. Donovan
- Health Services Research and Development, Veterans Affairs Puget Sound Health Care System, Seattle, Washington
- Division of Pulmonary, Critical Care, and Sleep Medicine, and
| | - Matthew F. Griffith
- Health Services Research and Development, Veterans Affairs Eastern Colorado Health Care System, Aurora, Colorado; and
- Division of Pulmonary Sciences and Critical Care, University of Colorado, Aurora, Colorado
| | - Thomas L. Keller
- Health Services Research and Development, Veterans Affairs Puget Sound Health Care System, Seattle, Washington
- Division of Pulmonary, Critical Care, and Sleep Medicine, and
| | - Alexander D. Bryant
- Health Services Research and Development, Veterans Affairs Puget Sound Health Care System, Seattle, Washington
- Division of Pulmonary, Critical Care, and Sleep Medicine, and
| | - David H. Au
- Health Services Research and Development, Veterans Affairs Puget Sound Health Care System, Seattle, Washington
- Division of Pulmonary, Critical Care, and Sleep Medicine, and
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10
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Nguyen T, Seiler N, Brown E, O'Donoghue B. The effect of Clinical Practice Guidelines on prescribing practice in mental health: A systematic review. Psychiatry Res 2020; 284:112671. [PMID: 31732189 DOI: 10.1016/j.psychres.2019.112671] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2019] [Revised: 10/29/2019] [Accepted: 10/31/2019] [Indexed: 01/03/2023]
Abstract
Clinical Practice Guidelines are succinct evidence-based recommendations and in psychiatry, exist to advise on psychotropic prescribing to effectively treat mental health conditions whilst minimising medication adverse effects. Implementation of psychiatric guidelines have, in the past, demonstrated little and transient impact on clinical practice. How effective prescribing guidelines are in aligning practice with evidence currently is unknown and this systematic review aimed to investigate said efficacy. Literature searches were performed on MEDLINE, EMBASE, and CINAHL up to September 2019 and articles were selected by two reviewers independently with discrepancies resolved by a third reviewer. The review identified 18 eligible articles pertaining to the following conditions: depressive disorders, psychotic disorders, post-traumatic stress disorder, anxiety disorders, bipolar affective disorder, attention deficit/hyperactivity disorder, borderline personality disorder, and opiate addiction with depression guidelines being the most frequently evaluated. Seven studies revealed guidelines effected no change in psychotropic prescribing. The remaining studies illustrated that even when practice was changed, the effect was generally small, emphasising the need to change guideline development and implementation, taking into account obstacles or opportunities specific to psychotropic pharmacotherapy.
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Affiliation(s)
- Tony Nguyen
- Orygen, The National Centre of Excellence in Youth Mental Health, 35 Poplar Road Parkville, Victoria 3052, Australia; Centre for Youth Mental Health, The University of Melbourne, 35 Poplar Road, Parkville, Victoria 3052, Australia
| | - Natalie Seiler
- Orygen, The National Centre of Excellence in Youth Mental Health, 35 Poplar Road Parkville, Victoria 3052, Australia; Centre for Youth Mental Health, The University of Melbourne, 35 Poplar Road, Parkville, Victoria 3052, Australia
| | - Ellie Brown
- Orygen, The National Centre of Excellence in Youth Mental Health, 35 Poplar Road Parkville, Victoria 3052, Australia; Centre for Youth Mental Health, The University of Melbourne, 35 Poplar Road, Parkville, Victoria 3052, Australia
| | - Brian O'Donoghue
- Orygen, The National Centre of Excellence in Youth Mental Health, 35 Poplar Road Parkville, Victoria 3052, Australia; Centre for Youth Mental Health, The University of Melbourne, 35 Poplar Road, Parkville, Victoria 3052, Australia; Orygen Youth Health, 35 Poplar Road, Parkville, Victoria 3052, Australia.
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Aguiar JP, Bernardo C, Gama Marques J, Leufkens H, Alves da Costa F. Identification of a Set of Patient-Related Features to Foster Safe Prescribing of Specific Antipsychotics in the Elderly With Dementia. Front Psychiatry 2020; 11:604201. [PMID: 33192746 PMCID: PMC7661963 DOI: 10.3389/fpsyt.2020.604201] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Accepted: 10/13/2020] [Indexed: 12/05/2022] Open
Abstract
Background: Antipsychotics (APs) are widely used to manage behavioral and psychiatric symptoms in dementia, although with a variety of adverse drug reactions. Therefore, it is important to know which patient-related features should be considered to foster a safe prescribing of these medications. Objectives: To compile and validate a set of patient-related features (PRFs) to foster safe prescribing of specific APs in the elderly with dementia; and to evaluate the feasibility of using them in clinical practice by analyzing the exhaustiveness of medical records. Method: A rapid literature review was the starting point, where PRFs were identified through a search in PubMed combined with information from the Summary of Product Characteristics (SmPCs). In the next step, a two-round e-Delphi survey was undertaken, where a total of 450 participants were invited by e-mail, including prescribers and specialists in benefit-risk assessment. Finally, a cross-sectional study was undertaken, where 100 patients were randomly extracted from the psychiatric hospital database. Outcomes were defined as the assessment of the clinical relevance and feasibility of the PRFs, and the level of exhaustiveness of these features in medical records. Data analysis was performed using univariate statistics (IBM SPSS v.23.0). Results: A total of 92 experts participated in the e-Delphi. Forty-seven PRFs obtained consensus, where 12 were applicable to haloperidol, 14 to olanzapine/risperidone, 13 to quetiapine, and 8 to aripiprazole. Age, comorbidities, and co-medications were rated as important features regardless of the prescribed drug. All PRFs were rated as always or frequently available and, if not, they were easy or partially easy to obtain. Age, comorbidities, and co-medications were always available in the medical records, whereas cognitive status (between 41.4 and 78.8%) or hepatic function (between 17.2 and 30.4%) presented a low-level of exhaustiveness. Conclusions: Even though a high number of PRFs were rated as clinically relevant, some of them were identified as frequently missing from medical records. This may suggest that medical records should be complemented with other sources (e.g., nursing and pharmacy records) to ensure a safe prescribing of APs.
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Affiliation(s)
- João Pedro Aguiar
- Faculdade de Farmácia, Research Institute for Medicines (iMED.ULisboa), Universidade de Lisboa, Lisbon, Portugal.,Centro de Investigação Interdisciplinar Egas Moniz (CiiEM), Instituto Universitário Egas Moniz (IUEM), Caparica, Portugal
| | - Catarina Bernardo
- Centro de Investigação Interdisciplinar Egas Moniz (CiiEM), Instituto Universitário Egas Moniz (IUEM), Caparica, Portugal
| | - João Gama Marques
- Hospital Júlio de Matos, Centro Hospitalar Psiquiátrico de Lisboa (CHPL), Lisbon, Portugal.,Faculdade de Medicina, Clínica Universitária de Psiquiatria e Psicologia Médica, Universidade de Lisboa (FMUL), Lisbon, Portugal
| | - Hubert Leufkens
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht, Netherlands
| | - Filipa Alves da Costa
- Faculdade de Farmácia, Research Institute for Medicines (iMED.ULisboa), Universidade de Lisboa, Lisbon, Portugal.,Centro de Investigação Interdisciplinar Egas Moniz (CiiEM), Instituto Universitário Egas Moniz (IUEM), Caparica, Portugal
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