Medication use in Italian nursing homes: preliminary results from the national monitoring system

Background: The aging population has increased concerns about the affordability, quality, and nature of long-term care for older people, emphasizing the role of nursing homes. Unlike acute hospital and primary care, there is a lack of drug consumption data in long-term care to understand regional or national healthcare policies. Objectives: This study aimed to describe medication consumption by older adults and expenditure in Italian nursing homes (NHs). Methods: Data on drug consumption and costs from the administrative medicine informational flows that detect medicines packages supplied to patients in health facilities and NHs were used. Data on the characteristics of the healthcare residence were from the Italian Health Ministry. Records for the year 2019, selecting the nursing homes exclusively providing elderly or mixed (elderly and disabled) were used. Results: In 2019, the total expenditure on medicines in NHs amounted to 25.38 million euros, the average cost to 1.30 and the expenditure per bed to 436.18 euros. Cardiovascular drugs were the highest-consuming therapeutic class (177.0 defined daily doses-DDDs/100 days of NH stay; 22.2% of total) followed by drugs acting on the alimentary tract and metabolism (167.6% and 21.0%) and blood drugs (160.4% and 20.1%). The treatment of hypertension and heart failure was widely the most frequently used, with the consumption being driven mainly by furosemide and ramipril. Antiulcer drugs were used on average in more than half of the days of NH stay (58.5 DDDs/100 days of NH stay), representing a therapeutic category for which deprescribing initiatives are recommended. On average, almost all patients received a dose of benzodiazepines, antipsychotics and antidepressants (37.6, 35.9, and 17.7 DDDs/100 days of NH stay, respectively), confirming the high prevalence of use for these medicines. Antibiotics reached 6.8 DDDs/100 days of NH stay. Conclusion: The availability of data in this specific setting allows the identification of the main interventions toward improving appropriateness and represents a challenge for drug utilization research. Data from this study suggest that proton pump inhibitors (PPIs), benzodiazepines and antibacterials can be areas of improving prescribing appropriateness.

Community use of antibiotics and development of bacterial resistance: a case-control study in Italy

Background

Antibiotic resistance is now a global emergency. An increasing number of infections are becoming difficult to treat and lead to longer hospitalizations, higher medical costs and increased mortality. The aim of this study is to assess, in a population at low prevalence of use of antibiotics, whether a previous use of these drugs is associated with the occurrence of clinically relevant resistance of E.coli to fluoroquinolones (FQs), one of the most widespread and critical bacteria resistance in Italy.

Methods

Through a data linkage of databases of the health information systems of the Province of Bolzano (Italy) a case-control study was carried out using 2016 data. All subjects for which the resistance of E. coli to FQs was tested by the regional microbiology reference laboratory were included in the study. Those with a positive FQs-resistant E.coli isolate were defined as cases (n = 409), while the others were considered controls (n = 933). For each subject the total number of prescriptions of any antibiotics and the total number of prescriptions of FQs in the previous year were detected through a record linkage with the drug prescription database. Information on potential confounding factors (age, gender, number of hospital admissions, days of hospitalization, number of surgeries, diagnosis of chronic diseases) were obtained from the database of hospital admissions. Multivariate logistic regression analysis was used to study the association between previous use of antibiotics (any and FQs only) and development of E.coli resistance to FQs.

Results

It was observed that for each unit increase in the number of prescriptions of any antibiotic, the probability for E.coli to develop FQs resistance significantly rises by 16%. This probability is much higher (45%) if the prescribed antibiotic is a FQ.

Conclusions

This study confirms the association between previous consumption of antibiotics and the onset of resistance even in an area with a low prevalence of use.

Key messages

The results of this study reiterate the need to prescribe and dispense antibiotics only when they are really needed. Health information systems allows to study the role of antibiotic use in the development of bacterial resistance, providing useful information for audit interventions among healthcare professionals.

Drug use and acute leukemia

OBJECTIVE

To study the occurrence of acute leukemia in relation to preceding use of drugs a case-control study has been carried out in Rome, Italy.

PATIENTS AND METHODS

Two hundred and two patients (age >15 years) with a diagnosis of acute leukemia during the period July 1992-June 1994 were enrolled. For each patient, 10 controls matched by age and gender were randomly drawn from the source population. Through the individual beneficiary code the information relevant to the drugs received within the National Health Service during the period January 1989-December 1992 was retrieved. The use of drugs was considered etiologically related to leukemia if the prescription occurred before the 12 months preceding the diagnosis. Exposure was categorized as 'any use' (at least one prescription during the etiologic period), 'high use' (duration of use greater than the median in the control group) and, for NSAIDs, 'very high use' (duration of use greater than 180 days).

RESULTS

Among drugs suspected to cause leukemia, users of high doses of chloramphenicol presented an OR of 1.8 (95% CI: 0.6-5.3). Among other categories of drugs with an increase in the ORs, though not statistically significant, we found tricyclic antidepressants (OR=1.7; 0.8-3.4) and oral contraceptives (OR=1.8; 0.8-4.0). No excess risk was observed for users of calcium-channel blockers (OR=0.9; 0.5-1.7). Use of very high doses of NSAIDs appeared to decrease the occurrence of acute leukemia (OR=0.4; 0.1-1.5).

CONCLUSION

Even with several limitations, this study provides an initial frame of reference for the potential causal role of drugs in acute leukemia.

Use of antiparkinsonian drugs in the Umbria Region

Discussion of differences between recommended guidelines and clinical practice is very useful in medicine. The use of a computerized database of all prescriptions of antiparkinsonian drugs enabled us to perform an epidemiological population-based study with low cost and in a relatively short time. We have identified 2 827 parkinsonian patients in November 2000 and estimate the number of patients taking dopaminoagonists aged >75 years, antidepressive drugs, and atypical neuroleptics.

Psychotropic drug use in Italy, 1984-99: the impact of a change in reimbursement status

After years of corruption surrounding drug reimbursement, in 1994, a change in drug reimbursement status was implemented in Italy according to cost-effectiveness criteria. The aim of this study was to assess the impact of these changes on the use of psychotropic drugs. National trends in antipsychotic, antidepressant and benzodiazepine prescriptions were analysed from 1984 to 1999. During the study period, prescriptions of antipsychotic drugs were stable from 1984 to 1994 but, in the subsequent 5 years, increased by 54%. Although the use of atypical compounds in 1999 accounted for only 6% of total antipsychotics sold, the cost of these new drugs accounted for almost one-half the total antipsychotic expenditure. The use of benzodiazepines increased by 53%. In 1999, the psychotropic drugs lorazepam and alprazolam were the most sold by value. From 1984 to 1999, the total antidepressants sold increased by 55%. Although the use of selective serotonin reuptake inhibitors and newer antidepressants in 1999 accounted for less than 50% of total antidepressants sold, the cost of these drugs accounted for 65% of total antidepressant expenditure. This analysis highlights specific areas of concern which should become the object of public health programs.

Niflumic acid and cutaneous reactions in children

In a case control study of adverse drug reactions in children, the odds ratio of developing a serious mucocutaneous event among users of niflumic acid, adjusted for concomitant use of all other drugs, was 4.9 (95% CI 1.9 to 12.8). Given the availability of safer analgesics and antipyretics, there is no indication, in our opinion, that requires the prescription of substances which bear an increased risk.

Continuous training as a key to increase the accuracy of administrative data

The aim of this study was to evaluate the impact of a program of training, education and awareness on the accuracy of the data collected from hospital discharge abstracts. Four random samples of hospital discharge abstracts relating to four different periods were studied. The evaluation of the impact of systematic training and education activities was performed by checking the quality of abstracting information from the medical records. The analysis was carried out at the Istituto Dermopatico dell'Immacolata, a research hospital (335 beds) in Rome, Italy, which specializes in dermatology, plastic and vascular surgery. Error rates in discharge abstracts were subdivided into six categories: selection of the wrong principal diagnosis (type A); low specificity of the principal diagnosis (type B); incomplete reporting of secondary diagnoses (type C); selection of the wrong principal procedure (type D); low specificity of the principal procedure (type E); incomplete reporting of procedures (type F). A specific rate for errors modifying classification in diagnosis related groups (DRG) was then estimated and the effect of re-abstracting on the case-mix index evaluated. Error types A, B, C, E and F dropped from 8.5% to 2%, 15.8 to 4.9, 31.8 to 13.1,4.1 to 0.3 and 22 to 2.6%, respectively. Error type D was 0.7 both in the first (the baseline) and fourth periods of analysis. All differences in error types were statistically significant. In 1999 8.3% of cases were assigned to a different DRG after re-abstracting as compared with 24.3% in the third quarter of 1994, 23.8% in the first quarter of 1995 and 5.5% in September-October 1997. Continuous training and feedback of information to departments have shown to be successful in improving the quality of abstracting information at patient level from the medical record. These positive results were facilitated by the introduction of a prospective payment system to finance inpatient hospital activity. The effort to increase administrative data quality at hospital level facilitates the use of those data sets for internal quality management activities.

[Characteristics of voluntarily discharged patients: some reflections and a proposal]

This study compares the characteristics of 492 patients discharged against medical advice from the Istituto Dermopatico dell'Immacolata, a Research Hospital (335 beds) in Rome specialized in Dermatology, Vascular Surgery and Plastic Surgery between 1995 and 1998, with those of 43,110 control patients discharged with physicians' approval according to a case-control model. In the multivariate analysis, male gender (OR 1.65; 95% CI 1.37-1.98) and residence in Rome area (OR 1.22; 95% CI 1.02-1.47) increased the odds of discharge against medical advice. The odds of such discharge decreased with increasing age (OR 0.994 per year; 95% CI 0.990-0.999). The proportion of patients discharged against medical advice decreased from 1.4% in 1995 to 0.4% in 1998. The average length of stay decreased from 1995 to 1998, with the exception of the Plastic Surgery unit. A retrospective review of the charts of 45 patients discharged against medical advice (AMA) within 48 hours from admission ascertained some of the stated reasons for discharge. Personal and family problems or refusal of treatment were reported for 35% of the patients. Of the 25 patients who gave no reasons, 11 asked again for hospitalization and 5 of these were rehospitalized by IDI within 10 days. This study also identified that the information on the medical record of patients who left against medical advice was generally poor. A standardized form for AMA discharges, including patient's understanding of the diagnosis, treatment, alternative therapies, consequences of refusing treatment and stated reasons for leaving against medical advice, might be of benefit to patients, physicians and hospital managers.

Active monitoring of adverse drug reactions in children. Italian Paediatric Pharmacosurveillance Multicenter Group

An active monitoring system of adverse drug reactions (ADR) in children was developed through a network of family paediatricians. The reported Incidence of ADRs was 15.1 per 1000 children.

The quality of abstracting medical information from the medical record: the impact of training programmes

OBJECTIVE

To evaluate the impact of a programme of training, education and awareness on the quality of the data collected through discharge abstracts.

STUDY DESIGN

Three random samples of hospital discharge abstracts relating to three different periods were studied. Quality control to evaluate the impact of systematic training and education activities was performed by checking the quality of abstracting medical records.

SETTING

The study was carried out at the Istituto Dermopatico dell'Immacolata, a research hospital in Rome, Italy; it has 335 beds specializing in dermatology and vascular surgery.

MEASURES

Error rates in discharge abstracts were subdivided into six categories: wrong selection of the principal diagnosis (type A); low specificity of the principal diagnosis (type B); incomplete reporting of secondary diagnoses (type C); wrong selection of the principal procedure (type D); low specificity of the principal procedure (type E); incomplete reporting of procedures (type F). A specific rate of errors modifying classification in diagnosis related groups was then estimated.

RESULTS

Error types A, B and F dropped from 8.5% to 1.3%, from 15.8% to 1.6% and from 22% to 2.6% respectively. Error type D and E were zero in the third period of analysis (September-October 1997) compared with a rate of 0.7% and 4.1% in the third quarter of 1994. Error type C showed a slight decrease from 31.8% in 1994 to 27.2% in 1997. All differences in error types except incomplete reporting of secondary diagnoses were statistically significant. Five and a half per cent of cases were assigned to a different diagnoses related group after re-abstracting in 1997 as compared to 24.3% in the third quarter of 1994 and 23.8% in the first quarter of 1995.

DISCUSSION

Training and continuous monitoring, and feedback of information to departments have proved to be successful in improving the quality of abstracting information at patient level from the medical record. The effort to increase administrative data quality at hospital level will facilitate the use of those data sets for internal quality management activities and for population-based quality of care studies.

Ketorolac use in outpatients and gastrointestinal hospitalization: a comparison with other non-steroidal anti-inflammatory drugs in Italy

OBJECTIVE

To compare the risk of hospitalization for gastroduodenal ulcer associated with the use of ketorolac and other non-steroidal anti-inflammatory drugs (NSAIDs).

METHODS

A cohort and a nested case-control study were carried out. All residents in the region of Umbria (Italy), aged 35-84 years, who had been given at least one NSAID prescription in 1993 and 1994 were identified. Exposure to drugs was ascertained through a drug prescription database. We estimated rate ratios of hospitalization for gastroduodenal ulcer with or without complications in the current, recent or past period according to exposure to different NSAIDs.

RESULTS

Rate ratio estimates, adjusted for age and sex, were 2.8 for any current NSAID and 1.4 for any recent NSAID. The highest rate ratios of lesions of any severity for current NSAID use were observed for piroxicam (RR: 4.6) and ketorolac (RR: 3.4). For gastrointestinal haemorrhage or perforation the highest rate ratios were those for ketorolac (RR: 5.9) and piroxicam (RR: 4.8). Rate ratio estimates did not change after adjustment for concomitant use of gastrotoxic drugs, use of gastroprotective agents not associated with NSAIDs and prior use of NSAIDs.

CONCLUSION

Our study demonstrates the need to adhere to the restrictions relating to the indications and duration of use of ketorolac. At present piroxicam represents a greater public health concern since it is confirmed to be among the most gastrotoxic NSAIDs and is one of the most commonly prescribed NSAIDs in Italy.

Prescriptions for mesalazine and sulphasalazine: a prevalence estimate of patients treated for inflammatory bowel disease in Rome

BACKGROUND

Sulphasalazine and 5-amino salicyclic acid drugs are specifically indicated for the treatment of inflammatory bowel disease.

AIM

To use drug consumption by a given population as a marker to estimate the number of patients with inflammatory bowel disease.

METHODS

Prescriptions for sulphasalazine and mesalazine were identified for the 133000 inhabitants of a local health unit in Rome. Other prescriptions received by the patients, who were users of sulphasalazine or mesalazine, were also studied.

RESULTS

99465 patients received at least one prescription for any drug in 1991. Three hundred and seventy-six patients were prescribed sulphasalazine and/or mesalazine, an average of 3.8 prescriptions per patient. These patients were exposed more frequently than the general population to other drugs often used in inflammatory bowel disease treatment, for example, corticosteroids, anti-diarrhoeal drugs and intestinal anti-infectives. We identified that 258 of 100000 inhabitants were prescribed either sulphasalazine or mesalazine; 127 of 100000 inhabitants received full-dose treatment for at least 30 days, and 42.8 of 100000 inhabitants received prescriptions of either drug, also associated with systemic corticosteroids.

CONCLUSION

The consumption of drugs used specifically for inflammatory bowel disease may act as a marker for the prevalence of the condition in a community.

Gangliosides and Guillain-Barré syndrome

Cases of Guillain-Barré syndrome (GBS) associated with parenteral use of gangliosides have been reported in several European countries. To evaluate the hypothesis of association between ganglioside exposure and occurrence of GBS, a case-control study was conducted. GBS cases discharged during 1989 from public and private hospitals in three Italian provinces were identified: 42 GBS cases and 420 controls matched on age and gender were enrolled. Data of onset of symptoms of GBS was taken from clinical records. Exposure status of subjects was ascertained through the regional computerized drug prescription monitoring system. The odds ratio of association between ganglioside use, in the 30 days prior to onset of symptoms, and GBS was 9.1 (95% confidence interval 2.8-29.4). Although there are formidable difficulties in distinguishing prodromal therapy of GBS from drug causation, the association with ganglioside therapy is strong and supportive of the hypothesis of a role of ganglioside preparations in the occurrence of GBS.

Use and misuse of antidepressant drugs in a random sample of the population of Rome, Italy

Prescribing patterns of antidepressant drugs were studied, over a period of 30 months, in a random sample of 8743 residents of the area of Rome, Italy. Data from the regional outpatient drug monitoring system were used. The proportion of subjects receiving, during the study period, at least one prescription of antidepressant drugs, was 5.4%; the female-to-male ratio was 2.1. Consumption prevalence increased with age. The single most prescribed drug was fluoxetine followed by amitriptyline and ademetionine. For a surprisingly high proportion of subjects, the observed length of treatment was shorter than expected on the basis of current knowledge in clinical pharmacology. Inappropriate diagnostic and therapeutic procedures are likely explanations.

Antipsychotic drug prescription in general practice in Italy

Prescribing patterns of neuroleptic drugs in a population of about 3,700,000 inhabitants were analysed using all individual prescriptions delivered by the Italian National Health Service during 4 years (1986-1989). Data contained in a regional prescription database were analysed using an outpatient drug monitoring system (VIDEOFAR). The proportion of subjects receiving neuroleptics was about 1.3% of the entire population. During 1989, 20.2% of 52,716 observed subjects received multiple neuroleptic therapy. Haloperidol, the most frequently prescribed antipsychotic, was dispensed to 21.3% of the individuals as the only neuroleptic treatment. Consumption sharply increased with age and about 60% of patients receiving a prescription were women. Nonetheless, among the heavy users in the younger ages, the male-to-female ratio is significantly greater than one. Although the principal indications for neuroleptics are subacute or chronic clinical conditions, a surprisingly high proportion of subjects (ranging from 48% to 76% depending on the type of neuroleptic) received only one single prescription during 1989.