Overlapping medication associated with healthcare switching among Korean elderly diabetic patients

Transfers between health facilities of people living with diabetes attending primary health care services in the Western Cape Province of South Africa: A retrospective cohort study

OBJECTIVES

Transfers between health facilities of people living with HIV attending primary health care (PHC) including hospital to PHC facility, PHC facility to hospital and PHC facility to PHC facility transfers occur frequently, affect health service planning, and are associated with disengagement from care and viraemia. Data on transfers among people living with diabetes attending PHC, particularly transfers between PHC facilities, are few. We assessed the transfer incidence rate of people living with diabetes attending PHC, and the association between transfers between PHC facilities and subsequent HbA1c values.

METHODS

We analysed data on HbA1c tests at public sector facilities in the Western Cape Province (2016-March 2020). Individuals with an HbA1c in 2016-2017 were followed-up for 27 months and included in the analysis if ≥18 years at first included HbA1c, ≥2 HbA1cs during follow-up and ≥1 HbA1c at a PHC facility. A visit interval was the duration between two consecutive HbA1cs. Successive HbA1cs at different facilities of any type indicated any transfer, and HbA1cs at different PHC facilities indicated a transfer between PHC facilities. Mixed effects logistic regression adjusted for sex, age, rural/urban facility attended at the start of the visit interval, disengagement (visit interval >14 months) and a hospital visit during follow-up assessed the association between transfers between PHC facilities and HbA1c >8%.

RESULTS

Among 102,813 participants, 22.6% had ≥1 transfer of any type. Including repeat transfers, there were 29,994 transfers (14.4 transfers per 100 person-years, 95% confidence interval [CI] 14.3-14.6). A total of 6996 (30.1%) of those who transferred had a transfer between PHC facilities. Visit intervals with a transfer between PHC facilities were longer (349 days, interquartile range [IQR] 211-503) than those without any transfer (330 days, IQR 182-422). The adjusted relative odds of an HbA1c ≥8% after a transfer between PHC facilities versus no transfer were 1.20 (95% CI 1.05-1.37).

CONCLUSION

The volume of transfers involving PHC facilities requires consideration when planning services. Individuals who transfer between PHC facilities require additional monitoring and support.

Comparison of Seegene Anyplex II HPV28 assay with BD Onclarity HPV assay for human papillomavirus genotyping

Presently, human papillomavirus (HPV)-based cervical cancer screening is commonly used and is replacing conventional cytology screening tests. The HPV genotyping assay is useful for triage in cervical cancer screening and the evaluation of HPV vaccination effects. In this study, we evaluated the clinical performance of two HPV genotyping assays, BD Onclarity HPV (Onclarity) and Seegene Anyplex II HPV28 (Anyplex) in the detection of relevant cervical lesions and for HPV genotyping concordance. Anyplex and Onclarity assays were performed on 920 consecutive liquid-based specimens. Anyplex, sensitivity, specificity, and genotyping concordance with Onclarity were optimal when restricted to ≥2+ (medium) viral loads. HPV genotyping agreement between the two assays ranged between 0.75 and 0.9 (excellent), except for HPV 33/58, which was 0.73 (good). With Onclarity as a reference, the relative sensitivity of Anyplex for the detection of ≥CIN 2 was 1.05 (95% CI: 0.99–1.1) and the relative specificity for detection of negative for intraepithelial lesion and malignancy (NILM) was 0.89 (95% CI: 0.85–0.93). For most ≥CIN 2 lesions, high-risk HPV was detected by Onclarity (66/72) and Anyplex (69/72) assays. For high-risk HPV negative ≥CIN 2 lesions, possible high-risk HPV genotypes were detected by Anyplex. In conclusion, the genotyping agreement between the tests was good to excellent. Full genotyping with Anyplex might confer additional benefits to patients with ≥CIN 2, although the difference is small. We also suggest an optimal cutoff value when reporting HPV infections using the Anyplex assay (≥2+; medium viral loads).

Interpersonal Continuity of Care and Its Effect on Health Care Utilizations and Expenditures for Diabetes: An Experience From a Fragmented Health System

We aimed to quantify continuity of care (COC) and investigate its association with health care utilizations and expenditure among patients with diabetes. This was an observational retrospective cohort study using administrative claims database of Iranian Health Insurance Organization for East Azerbaijan Province, Iran. Standard indices of COC were calculated for each patient, and their associations with utilization outcomes were determined by applying general linear regression models. A total of 32 263 patients were included (mean age: 60.9 ± 14.5 years; 64% females). Higher levels of COC were associated with a reduced number and spending of all health care service categories.

Adherence and Associated Factors of Treatment Regimen in Drug-Susceptible Tuberculosis Patients

Background: Adherence to tuberculosis (TB) drugs is one of the key aspects of global TB control, yet there is a lack of epidemiological evidence on the factors influencing adherence to TB drugs. Thus, this study aimed to explore the adherence and factors associated with adherence among TB patients in South Korea. Methods: We conducted a cohort study using a sampled national healthcare database from 2017 to 2018. Our study population included incident TB patients initiating quadruple or triple regimen who were available for follow-up for 180-days. Adherence was evaluated using the proportion of days covered (PDC): 1) adherent group: patients with PDC ≥80%; 2) non-adherent group: patients with PDC <80%. Kaplan-Meier analysis was conducted to calculate the median time-to-discontinuation in the study population. We calculated the adjusted odds ratios (aOR) with 95% confidence intervals (CI) to assess factors associated with adherence to TB drugs using logistic regression. Results: Of 987 patients, 558 (56.5%) were adherent and 429 (43.5%) were non-adherent, with the overall mean PDC of 68.87% (standard deviation, 33.37%). The median time-to-discontinuation was 113 days (interquartile range 96-136) in the study population. Patients initiating quadruple regimen were more likely to adhere in comparison to the triple regimen (aOR 4.14; 95% CI 2.78-6.17), while those aged ≥65 years (aOR 0.53; 95% CI 0.35-0.81), with a history of dementia (aOR 0.53; 95% CI 0.34-0.85), and with history of diabetes mellitus (aOR 0.70; 95% CI 0.52-0.96) were less likely to adhere to the drug. Conclusion: Approximately 45% of TB patients were non-adherent to the drug, which is a major concern for the treatment outcome. We call for intensified attention from the authorities and healthcare providers to reinforce patients' adherence to the prescribed TB drugs.

Transfer of primary care patients receiving chronic care: the next step in the continuum of care

The burden of chronic conditions is increasing rapidly in low- and middle-income countries. Chronic conditions require long-term and continuous care, including for patients transferring between facilities. Patient transfer is particularly important in the context of health service decentralization, which has led to increasing numbers of primary care facilities at which patients can access care, and high levels of migration, which suggest that patients might require care at multiple facilities. This article provides a critical review of existing evidence regarding transfer of stable patients receiving primary care for chronic conditions. Patient transfer has received limited consideration in people living with HIV, with growing concern that patients who transfer are at risk of poor outcomes; this appears similar for people with TB, although studies are few. There are minimal data on transfer of patients with non-communicable diseases, including diabetes. Patient transfer for chronic conditions has thus received surprisingly little attention from researchers; considering the potential risks, more research is urgently required regarding reasons for and outcomes of transfers, transfer processes and interventions to optimize transfers, for different chronic conditions. Ultimately, it is the responsibility of health systems to facilitate successful transfers, and this issue requires increased attention from researchers and policy-makers.

Prevalence and Risk of Polypharmacy among Community-Dwelling, Elderly Kuwaiti Patients

OBJECTIVES

To estimate the prevalence of polypharmacy in community-dwelling, older Kuwaiti patients, describe the number and types of drugs used, and identify risk factors associated with polypharmacy.

SUBJECTS AND METHODS

This was a descriptive cross-sectional questionnaire-based survey in which we interviewed 500 community-dwelling Kuwaiti adults over 65 years of age. The data collection occurred during a 4-month period from March to July 2017.

RESULTS

Fifty-two percent (n = 260) of the patients were males, with a mean age of 71.73 ± 5.32 years. The prevalence of polypharmacy (5-8 drugs) and excessive polypharmacy (>8 drugs) was 58.4% (n = 292) and 10.2% (n = 51), respectively. The risk factors associated with an increased number of medicines used were: female gender (p = 0.019), a lower level of education (p = 0.003), a high number of hospital admissions (p = 0.000), clinics visited by the patient (p =0.000), and number of comorbidities (p = 0.000). The most commonly used medications (82.6% of the study population) were blood glucose-lowering agents, excluding insulin. Other commonly used medications were antihypertensive drugs and lipid-modifying agents.

CONCLUSION

A significant sector of the older Kuwaiti patient population has a high prevalence of polypharmacy and is thus exposed to its potential hazards. The current study highlights the need to revise the drug-dispensing policy among community-dwelling, older Kuwaiti people, as well as to initiate educational programs among healthcare practitioners concerning prescribing issues in older individuals.

Effect of Statins, Metformin, Angiotensin-Converting Enzyme Inhibitors, and Angiotensin II Receptor Blockers on Age-Related Macular Degeneration

PURPOSE

Statins, metformin, angiotensin-converting enzyme (ACE) inhibitors, and angiotensin receptor blockers (ARBs) have been suggested for treating age-related macular degeneration (AMD) due to their pleiotropic effects. Therefore, we investigated whether these drugs prevent AMD.

MATERIALS AND METHODS

We conducted a nested case-control study using the Korean National Health Insurance Service database. Using risk-set sampling of age, sex, cohort entry date, and follow-up duration, we identified incident patients with AMD and 10 matching controls in cohorts with diabetes mellitus or cardiovascular diseases. Exposure was assessed within one year before the index date using patient prescription records. We conducted conditional logistic regression to estimate the odds ratios (ORs) and 95% confidence intervals (CIs) to evaluate the association between cardiovascular medications and AMD.

RESULTS

Our study included 2330 cases and 23278 controls from a cohort of 231274 patients. The ORs (95% CI) for AMD occurrence in users prescribed with statins, metformin, ACE inhibitors, and ARBs were 1.12 (0.94-1.32), 1.15 (0.91-1.45), 0.90 (0.61-1.34), and 1.21 (1.05-1.39), respectively. A duration-response was not observed.

CONCLUSION

Statins, metformin, ACE inhibitors, and ARBs did not inhibit AMD in elderly patients. The absence of a duration-response supports the lack of a causal relationship.

Decrease in use of contraindicated drugs with automated alerts in children

BACKGROUND

This study evaluated changes in the use of contraindicated drugs in the pediatric population, via automated alerts through the nationwide drug utilization review.

METHODS

We conducted an interrupted time series analysis using the nationwide health insurance database. Study drugs consisted of a total of 72 drugs in 22 classes that were designated as age contraindicated between January 2007 and December 2011. The subjects consisted of the patients in Korea who had been prescribed with any of the study drugs at least once. Changes in the use of age-contraindicated drugs after the regulatory action were estimated as relative and absolute reductions with 95% CI. Regression analysis was carried out based on the monthly number of users prior to the announcement of age-contraindicated drugs on 3 December 2009 to estimate the predicted values, and these were then compared with the observed values after the announcement.

RESULTS

A total of 2 541 888 patients were prescribed age-contraindicated drugs at least once. The percentage of age-contraindicated drug users was 2.10% of the total users (n = 3 309 566) during the period prior to the 2009 regulatory action, but it decreased to 0.30% (n = 542 529) after the action. Overall, there was an 85.71% relative reduction (95% CI: 71.53-102.72) in the percentage of age-contraindicated drug users. The projected monthly number of users of age-contraindicated drugs showed a gradual downward trend.

CONCLUSION

Decreases in contraindicated drugs have accelerated after a regulatory action with automated alerts.

Differential Risk of Peptic Ulcer Among Users of Antidepressants Combined With Nonsteroidal Anti-inflammatory Drugs

BACKGROUND

Selective serotonin reuptake inhibitors (SSRIs) have been reported to have an increased risk of gastrointestinal adverse events, and the risk may be further increased by combined use of nonsteroidal anti-inflammatory drugs (NSAIDs). However, little has been known about the risk of peptic ulcer associated with other classes of antidepressants or individual antidepressants combined with NSAIDs.

METHODS

We conducted a retrospective cohort study to define the risk of peptic ulcer associated with combined use of antidepressants and NSAIDs, as compared with use of antidepressants alone. Using the Korean Health Insurance Review and Assessment Service database, we identified a total of 1,127,622 patients who began receiving antidepressants between 2009 and 2012. Propensity-based matching and Cox proportional hazards models were used to compare the risk of peptic ulcer between antidepressant users with NSAIDs and those without NSAIDs matched in a 1:1 ratio, for a total of 768,850 patients.

RESULTS

The risk of peptic ulcer did not increase with combined use of overall antidepressants and NSAIDs, as compared with antidepressant use alone (hazard ratio [HR], 1.02; 95% confidence interval [CI], 0.99-1.06). A slightly increased risk was observed for combined use of NSAIDs with tricyclic antidepressants (HR, 1.15; 95% CI, 1.09-1.21) and with SSRIs (HR, 1.08; 95% CI, 1.01-1.16).

CONCLUSION

We found that although concomitant use of NSAIDs and antidepressants was not associated with an increased risk of peptic ulcer for antidepressants in general, it was so for some specific classes including tricyclic antidepressants and SSRIs. However, we cannot rule out the possibility that the increased risk was solely due to NSAID use.

Therapy discontinuation or substitution in patients with cardiovascular disease, switching among different products of the same off-patent active substance: a 'real-world' retrospective cohort study

OBJECTIVE

The present study investigated the effects of switching to different products of the same off-patent active substance (brand name or generic) on therapy discontinuation or substitution with another molecule of the same class, in patients with cardiovascular disease treated with statins and antihypertensives in a 'real-world' setting.

DESIGN

A retrospective cohort study in a 'real-world' setting.

SETTING

Analysis of data performed by integrating administrative databases that included approximately two million individuals who are assisted by the National Health System from three Local Health Units located in three different regions of Italy.

PARTICIPANTS

All patients aged ≥18 years with at least one prescription of simvastatin, ramipril or amlodipine in the period 1 January to 31 December 2010 were included and followed up for 2 years.

MAIN OUTCOME MEASURES

Prescription refills occurring during follow-up were evaluated. Frequency of discontinuation of therapy or substitution with another molecule of the same class (eg, from simvastatin to a different statin) during follow-up was identified.

RESULTS

During follow-up, therapy discontinuation or substitution was found to be more frequent in patients switching to a different product of the same active substance compared with non-switching patients (11.5% vs 10.8% and 22.2% vs 20.8% (p=0.002), respectively, in the simvastatin group; 4.0% vs 3.5% and 24.6% vs 22.7% (p<0.001), respectively, in the amlodipine group). In the ramipril group, 8% of patients undertook a therapy substitution to another molecule; no trend towards a lower percentage of substitution was observed in the non-switching group, while 18% of patients discontinued treatment, with a significant difference in favour of patients not switching. These findings were partially confirmed by multivariate analysis.

CONCLUSIONS

Switches among products of the same active substance are quite common in patients with cardiovascular disease. Our study suggests that switching may expose patients to a higher risk of therapy discontinuation or substitution.

Risk of motor vehicle collisions associated with medical conditions and medications: rationale and study protocol

BACKGROUND

Medical conditions and medications may be associated with motor vehicle collisions (MVCs), which pose a major public health problem worldwide. Further epidemiological assessment is necessary for certain diseases and medications. Moreover, since disease aetiology and patterns of medication use may differ among ethnicities and healthcare systems, a population-specific approach is necessary. The present epidemiological study is designed to assess the medical conditions and medications associated with the risk of fatal MVCs among at-fault drivers in the Korean population.

METHOD AND DESIGN

A retrospective cohort will be constructed for individuals who died in MVCs between 2005 and 2014 in the Korean Traffic Accident Analysis System database, which is linked to the Korean National Health Insurance database between 2002 and 2014. In order to compare medical conditions and medication use among drivers who died in a fatal MVC with the general population, standardised prevalence ratios will be calculated. In the culpability study, we will identify conditions and drugs associated with MVCs, comparing drivers with higher levels of responsibility to those with lower levels of responsibility. In the case-crossover study, the transient effects of medical conditions and medications will be examined using a conditional logistic regression model that adjusts for confounders.

DISCUSSION

The results of this study will help to characterise the associations of diseases and medications with fatal MVCs in an Asian population, with the goal of informing regulatory and clinical decision-making regarding patients with the relevant conditions and the establishment of strategies for improving traffic safety.

A comparison of risperidone and haloperidol for the risk of ischemic stroke in the elderly: a propensity score-matched cohort analysis

OBJECTIVE

With an increase in antipsychotic use in the elderly, the safety profile of antipsychotics has been emphasized. Strong concerns have been raised about whether the risk of ischemic stroke differs between risperidone and haloperidol. This study compared the risk of ischemic stroke between elderly patients taking risperidone and haloperidol.

METHOD

We conducted a retrospective cohort study using the Korea Health Insurance Review and Assessment Service database, applying a propensity-matched analysis. The cohort consisted of elderly patients who were newly prescribed haloperidol or risperidone between January 1, 2006 and December 31, 2009. Patients with prior cerebrovascular diseases (ICD-10, I60-I69), transient ischemic attack (ICD-10, G45), or cerebral tumors (ICD-10, C31) during 365 days prior to the initiation date were excluded. The study subjects were selected by propensity score matching. The outcome was defined as the first hospitalization for ischemic stroke (ICD-10, I63). Cox regression models were used to estimate the hazard ratio (HR) and 95% confidence intervals (95% CI) for ischemic stroke with haloperidol compared with risperidone use.

RESULTS

A total of 14,103 patients were included in the propensity-matched cohort for each drug. Overall, the incidence rate was higher for haloperidol users compared to the risperidone users (6.43 per 1000 person-years vs. 2.88 per 1000 person-years). A substantially increased risk was observed in haloperidol users (adjusted HR = 2.02, 95% CI, 1.12-3.62).

CONCLUSIONS

The evidence showed that haloperidol should be prescribed in the elderly with caution.

Probable transmission chains of Middle East respiratory syndrome coronavirus and the multiple generations of secondary infection in South Korea

•

As of July 14, 2015, the South Korean outbreak of Middle East respiratory syndrome coronavirus (MERS-CoV) infection has involved 185 secondary infections belonging to three overlapping generations of cases who have contracted the virus almost exclusively in the healthcare environment.

•

Fomite transmission may explain a significant proportion of the infections occurring in the absence of direct contact with infected cases.

•

The analysis of publicly available data collected from multiple sources, including the media, is useful for describing the epidemic history of an infectious disease outbreak.

Background

In May 2015, South Korea reported its first case of Middle East respiratory syndrome coronavirus (MERS-CoV) infection in a 68-year-old man with a history of travel in the Middle East. In the presence of secondary infections, an understanding of the transmission dynamics of the virus is crucial. The aim of this study was to characterize the transmission chains of MERS-CoV infection in the current South Korean outbreak.

Methods

Individual-level data from multiple sources were collected and used for epidemiological analyses.

Results

As of July 14, 2015, 185 confirmed cases of MERS have been reported in the Korean outbreak. Three generations of secondary infection, with over half belonging to the second generation, could be delineated. Hospital infection was found to be the most important cause of virus transmission, affecting largely non-healthcare workers (154/184). Healthcare switching has probably accounted for the emergence of multiple generations of secondary infection. Fomite transmission may explain a significant proportion of the infections occurring in the absence of direct contact with infected cases.

Conclusions

Publicly available data from multiple sources, including the media, are useful to describe the epidemic history of an outbreak. The effective control of MERS-CoV hinges on the upholding of infection control standards and an understanding of health-seeking behaviours in the community.

Risk of intracranial haemorrhage in antidepressant users with concurrent use of non-steroidal anti-inflammatory drugs: nationwide propensity score matched study

OBJECTIVE

To define the risk of intracranial haemorrhage among patients treated with antidepressants and non-steroid anti-inflammatory drugs (NSAIDs), compared with the risk among those treated with antidepressants without NSAIDs.

DESIGN

Retrospective nationwide propensity score matched cohort study.

SETTING

Korean nationwide health insurance database between 1 January 2009 and 31 December 2013.

PARTICIPANTS

Patients who began receiving antidepressants for the first time (index date) without a history of having received a prescription for antidepressants during the preceding year. Patients who had been diagnosed as having cerebrovascular diseases within a year before the index date were excluded.

MAIN OUTCOME MEASURE

Time to first hospital admission with intracranial haemorrhage within 30 days after drug use. Matched Cox regression models were used to compare the risk of intracranial haemorrhage among patients who were treated with antidepressants with and without NSAIDs, after propensity score matching with a 1:1 ratio.

RESULTS

After propensity score estimation and matching in a 1:1 ratio, the cohort used in the analysis included 4,145,226 people. The 30 day risk of intracranial haemorrhage during the entire study period was higher for combined use of antidepressants and NSAIDs than for use of antidepressants without NSAIDs (hazard ratio 1.6, 95% confidence interval 1.32 to 1.85). No statistically meaningful differences were found in risk of intracranial haemorrhage between the antidepressant drug classes.

CONCLUSIONS

Combined use of antidepressants and NSAIDs was associated with an increased risk of intracranial haemorrhage within 30 days of initial combination.

Regulatory action and moderate decrease in methylphenidate use among ADHD diagnosed patients aged five and under in Korea

In December 2009, Korean regulatory agency announced that methylphenidate, a drug used to treat attention deficit-hyperactivity disorder (ADHD), should not be used in children aged five and under due to the risk of sudden cardiac death. This study examined the impact of regulatory action and prescribing patterns. We conducted a time series analysis using the Korea National Health Insurance Service database. Study subjects included children under 18years old with ADHD from January 2007 to December 2011. Contraindicated use of methylphenidate was defined as use of methylphenidate at least once in children aged five and under. We selected additional control points (2007, 2008, and 2010) and compared the methylphenidate use one year before and after each point. We calculated relative and absolute reductions, and 95% confidence intervals. The total number of ADHD patients was 376,298. Overall, there was a 70.87% relative reduction (95% CI: 63.33%-79.31%) and a 0.93% absolute reduction (95% CI: 0.51%-0.60%) of methylphenidate use. The relative and absolute reductions were 27.61% (95% CI: 24.76%-30.78%) and 0.31% (95% CI: 0.21%-0.41%) in 2007; 43.58% (95% CI: 38.02%-49.96%) and 0.35% (95% CI: 0.27%-0.43%) in 2008; 46.52% (95% CI: 38.86%-55.70%) and 0.21 (95% CI: 0.15%-0.27%) in 2009; and 10.20% (95% CI: 8.32%-12.50%) and 0.02% (95% CI: 0.02%-0.07%) in 2010. Korean regulatory action led to a moderate decrease in contraindicated methylphenidate use even after the steep decline before the regulatory action.

Risk of ischemic stroke associated with the use of antipsychotic drugs in elderly patients: a retrospective cohort study in Korea

Objective

Strong concerns have been raised about whether the risk of ischemic stroke differs between conventional antipsychotics (CAPs) and atypical antipsychotics (AAPs). This study compared the risk of ischemic stroke in elderly patients taking CAPs and AAPs.

Method

We conducted a retrospective cohort study of 71,584 elderly patients who were newly prescribed the CAPs (haloperidol or chlorpromazine) and those prescribed the AAPs (risperidone, quetiapine, or olanzapine). We used the National Claims Database from the Health Insurance Review and Assessment Service (HIRA) from January 1, 2006 to December 31, 2009. Incident cases for ischemic stroke (ICD-10, I63) were identified. The hazard ratios (HR) for AAPs, CAPs, and for each antipsychotic were calculated using multivariable Cox regression models, with risperidone as a reference.

Results

Among a total of 71,584 patients, 24,668 patients were on risperidone, 15,860 patients on quetiapine, 3,888 patients on olanzapine, 19,564 patients on haloperidol, and 7,604 patients on chlorpromazine. A substantially higher risk was observed with chlorpromazine (HR = 3.47, 95% CI, 1.97–5.38), which was followed by haloperidol (HR = 2.43, 95% CI, 1.18–3.14), quetiapine (HR = 1.23, 95% CI, 0.78–2.12), and olanzapine (HR = 1.12, 95% CI, 0.59–2.75). Patients who were prescribed chlorpromazine for longer than 150 days showed a higher risk (HR = 3.60, 95% CI, 1.83–6.02) than those who took it for a shorter period of time.

Conclusions

A much greater risk of ischemic stroke was observed in patients who used chlorpromazine and haloperidol compared to risperidone. The evidence suggested that there is a strong need to exercise caution while prescribing these agents to the elderly in light of severe adverse events with atypical antipsychotics.

Dramatic decrease in fluoroquinolones in the pediatric population in Korea

PURPOSE

This study was performed to evaluate the change of prescribing patterns after the regulatory action regarding fluoroquinolones in pediatric patients.

METHODS

We conducted a time series analysis using the Korea Health Insurance Review and Assessment Service National Patients Sample database. Study subjects consisted of pediatric patients under 18 years of age who were prescribed antibiotics at least once (ATC code, J01) before (January 2009-December 2009) and after implementation (January 2010-December 2011) of the regulation. The use of fluoroquinolones was defined as the use of the following antibiotics for at least once in pediatric patients: ofloxacin, ciprofloxacin, norfloxacin, lomefloxacin, levofloxacin, and gemifloxacin. We calculated the number of pediatric fluoroquinolone users for each month. The difference between proportions before and after the regulation was estimated as relative and absolute reduction of fluoroquinolone use. We calculated 95% confidence intervals (CI).

RESULTS

We identified 4, 945, 169 antibiotic prescriptions in 484, 914 pediatric patients. During the 12-month period before implementation, percentage of fluoroquinolone use was 4.81% (95% CI: 4.70-4.91%, N = 8001). We observed a rapid decrease in the monthly number of fluoroquinolone users in pediatric population after the implementation of regulatory action. In the year after regulatory action, the percentage of fluoroquinolone use was only 0.26% (95% CI: 0.24-0.28%, N = 834). Overall, there was a 94.55% relative reduction (95% CI: 88.02-101.56%) in the use of fluoroquinolones.

CONCLUSION

Korean regulatory actions regarding fluoroquinolones had an effect of reducing use in pediatric population.

Prevalence and predictors of polypharmacy among Korean elderly

OBJECTIVE

Polypharmacy is widespread in the elderly because of their multiple chronic health problems. The objective of this study was to investigate the prevalence and predictors associated with polypharmacy in a nationally representative sample of Korean elderly individuals.

METHODS

We used the Korea Health Insurance Review and Assessment Service - National Patient Sample (HIRA-NPS) data from 2010 and 2011. We used information on 319,185 elderly patients (aged 65 years or older) between January 1, 2010 and December 31, 2011 from the HIRA-NPS database. We defined 'polypharmacy' as the concurrent use of 6 medications or more per person, 'major polypharmacy' as 11 medications or more, and 'excessive polypharmacy' as 21 medications or more. The frequency and proportion (%) and their 95% confidence intervals were presented according to the polypharmacy definition. Polypharmacy was visualized by the Quantum Geographic Information Systems (QGIS) program to describe regional differences in patterns of drug use. Multivariate ordinal logistic regression was performed to estimate odds ratios (ORs) and their 95% confidence intervals (CI) to investigate the risk factors for polypharmacy.

RESULTS

Of the Korean elderly studied, 86.4% had polypharmacy, 44.9% had major polypharmacy and 3.0% had excessive polypharmacy. Polypharmacy was found to be primarily concentrated in the Southwest region of the country. Significant associations between polypharmacy and the lower-income Medical Aid population (OR = 1.52, 95% CI 1.47, 1.56) compared with National Health Insurance patients was observed.

CONCLUSIONS

Nationwide efforts are needed for managing polypharmacy among Korean elderly patients. In particular, a national campaign and education to promote appropriate use of medicines for the Medical Aid population is needed.

Measuring fragmentation of ambulatory care in a tripartite healthcare system

BACKGROUND

Hong Kong has a tripartite healthcare system, where western medicine provided in both public and private sectors coexist with Chinese medicine practice. The purpose of this study is to measure fragmentation of ambulatory care experienced by the non-institutionalized population aged 15 and over in such a tripartite system, thus shed light on the ongoing primary care reform.

METHODS

This is a cross-sectional secondary data analysis using the Thematic Household Survey, which was conducted by the Hong Kong Census and Statistics Department during November 2009 to February 2010 to collect territory-wide health-related information. Among 18,226 individuals with two or more ambulatory visits during the past 12 months before interview, we grouped each visit into one of the three care segments-public western, private western and Chinese medicine. Two individual-level measures were used to quantify longitudinal fragmentation of care across segments over the one-year period: Most Frequent Provider Continuity Index (MFPC) and Fragmentation of Care Index (FCI). Both are analyzed for distribution and subgroup comparison. A Tobit model was used to further examine the determinants of fragmentation.

RESULTS

More than a quarter of individuals sought care in two or all three segments, with an average MFPC of 65% and FCI of 0.528. Being older, female, married, unemployed, uninsured, or born in mainland China, with lower education, lower income, higher number of chronic conditions or poorer health were found to have experienced higher fragmentation of care. We also found that, fragmentation of care increased with the total number of ambulatory care visits and it varied significantly depending on what segment the individual chose to visit most frequently-those chose private western clinics had lower FCI, compared with those chose public western or Chinese medicine as the most frequently visited segment.

CONCLUSIONS

Even measured at healthcare segment level, people in Hong Kong experienced modest fragmentation of care. Individuals' health beliefs-as a result of the persistent habitual tendency and latitude incentivized by the system-may be behind the fragmented care we saw. Efforts are needed to alter health beliefs, targeting subgroups of vulnerable population, and create environments that promote better coordinated primary care.