Antivirals and antibiotics for influenza in the United States, 1995--2002

PURPOSE: To measure the rates of antiviral and antibiotic prescribing for patients diagnosed with influenza in the United States. METHODS: We performed a retrospective analysis of visits to ambulatory clinics and emergency departments in the National Ambulatory Medical Care Survey (NAMCS) and the National Hospital Ambulatory Medical Care Survey (NHAMCS) with a diagnosis of influenza that occurred in seven influenza seasons between 1 October 1995 and 31 May 2002 (n=1216). RESULTS: There were an estimated 22 million visits (95%CI, 17--26 million visits) with a diagnosis of influenza to community ambulatory clinics (88% of visits), hospital ambulatory clinics (3%) and emergency departments (9%) in the United States between the 1995--1996 and the 2001--2002 influenza seasons, inclusive. The sample was 63% adults, 44% male and 84% white. Physicians prescribed antivirals in 19% of visits and antibiotics not associated with an antibiotic-appropriate diagnosis in 26% of visits. In multivariable modeling, independent predictors of antiviral prescribing were adult age (OR, 2.1; 95%CI, 1.1--4.0) and Medicare insurance (OR, 0.1 compared to private insurance; 95%CI, 0.0--0.6). Antiviral prescribing was marginally associated with influenza season (OR, 1.2 per influenza season; 95%CI, 1.0--1.4). Independent predictors of antibiotic prescribing were influenza season (OR, 0.8 per influenza season; 95%CI, 0.7--0.9), male sex (OR, 0.6; 95%CI, 0.4--0.9), adult age (OR, 2.3; 95%CI, 1.2--4.2) and emergency department visits (OR, 0.5 compared to community ambulatory visits; 95%CI, 0.3--0.8). CONCLUSIONS: Physicians prescribed antiviral medications to 19% of patients they diagnosed with influenza; the proportion that would have been clinically appropriate is unknown. In contrast, physicians prescribed apparently inappropriate antibiotics to 26% of these same patients, a rate that, encouragingly, decreased over time.     

National antidepressant prescribing in children and adolescents with mental health disorders after an FDA boxed warning

BackgroundIn October 2004, the U.S. Food and Drug Administration (FDA) issued a boxed warning about an increased risk of suicidality (i.e., suicidal ideation, behavior, or attempts) related to all antidepressants in children and adolescents.ObjectiveTo describe national antidepressant prescribing patterns in children and adolescents before, during, and after the introduction of the FDA boxed warning.MethodsCross-sectional data from the 2002–2009 National Ambulatory Medical Care Survey (NAMCS) and National Hospital Ambulatory Medical Care Survey (NHAMCS) were used to describe antidepressant prescribing patterns within a nationally-representative sample of 4035 physician visits for children and adolescents diagnosed with depression or other psychiatric disorder(s) [i.e., anxiety disorders or attention deficit/hyperactivity disorder (ADHD)].ResultsIn 2002–2003, antidepressants were prescribed in 4.1 million (36.1%) visits, followed by 3.2 million (28.8%) visits in 2004–2005 and 2.8 million (26.8%) visits in 2006–2007. However, antidepressant prescribing patterns reversed during 2008–2009, with an increase to 3.6 million (32.5%) visits. Compared to the period preceding the FDA boxed warning (2002–2003), a significant decline in visits related to antidepressant prescribing detected in the immediate post-FDA boxed warning period (2006–2007) (AOR = 0.67, 95% CI: 0.47–0.96). No association between the FDA boxed warning and antidepressant prescribing visits was detected during the FDA boxed warning period (2004–2005) (AOR = 0.80, 95% CI: 0.53–1.21) and in the late post-FDA boxed warning period (2008–2009) (AOR = 1.01, 95% CI: 0.63–1.60).ConclusionsAfter a 2-year lag period, antidepressant prescribing for visits of children and adolescents diagnosed with depression or other psychiatric disorder(s) in community-based and outpatient clinic settings declined when compared to the period preceding the FDA boxed warning. This decline was not sustained in the period of five years after implementation of the FDA boxed warning.     

Trends in prescribing for vulvovaginal candidiasis in the United States

PURPOSE: To describe trends in visits to office-based physicians in the United States by females 15-64 years of age for vulvovaginal candidiasis and related antifungal prescribing. Since January 1991, intravaginal antifungal medications have been available over-the-counter in the United States to treat vulvovaginal candidiasis. METHODS: Data from the 1985 through 2001 National Ambulatory Medical Care Surveys (NAMCS) were examined. NAMCS is an annual national probability sample survey that collects data on the utilization of services provided by office-based physicians. RESULTS: The average annual visit rates for symptoms of vaginitis and a diagnosis of vulvovaginal candidiasis decreased by 55 and 72%, respectively. The intravaginal antifungal prescribing rate for vulvovaginal candidiasis declined by 41%. No trend was found for total antifungal prescribing; however, during the late 1990s, fluconazole was prescribed at approximately one-third of visits with a diagnosis of vulvovaginal candidiasis. CONCLUSION: These data suggest an increased trend in self-diagnosis and use of over-the-counter intravaginal antifungal medications. The shift from prescribing intravaginal antifungal preparations to fluconazole raises concern about the possible development of azole drug resistance. Educational efforts are needed to counter potential misuse of these medications that may contribute to increased infection with innately azole resistant non-albicans Candida species and chronic infection.     

Utilization of hospital and outpatient care for adverse cutaneous reactions to medications

PURPOSE: To quantify hospitalizations, visits to office based physicians, hospital clinics and emergency departments with primary diagnoses of skin conditions that are often due to drug reaction. METHODS: I analyzed data from the National Hospital Discharge Summary (1997-2001), National Ambulatory Care Survey (1995-2000) and National Hospital Ambulatory Care Survey (1995-2000) to determine the number of hospitalizations and visits with primary diagnoses of skin conditions that are often attributed to drugs. Using statistical methods for surveys, I determined the demographic characteristics of patients with these diagnoses and compared them with patients seeking care for other reasons. RESULTS: In the United States, there are about 5000 hospitalizations each year with a primary diagnosis of erythema multiform, Stevens-Johnson Syndrome or Toxic Epidermal Necrolysis, of which 35% are specifically ascribed to drugs. Annually, there are more than 100,000 outpatient visits for these diagnoses and about two million visits for immediate hypersensitivity reactions that may be due to drugs. Outpatient visits for drug eruptions and drug allergies that include a skin component exceed 500,000 annually. CONCLUSIONS: Skin conditions often attributed to drugs are frequent reasons for hospitalization and physician visits. Optimal care of the individual patients with these conditions requires careful attention to drugs as a possible cause.     

Visits to office-based physicians in the United States for medication-related morbidity.

OBJECTIVE: To examine the prevalence, nature, demographics, and resource use associated with visits to office-based physicians in the United States during 1995 for medication-related morbidity. DESIGN: A nationwide cross-sectional survey of ambulatory care visits to physician offices, based on data from the National Center for Health Statistics' 1995 National Ambulatory Medical Care Survey. SETTING: Physician office-based settings in the United States. PATIENTS: Patients visiting office-based physicians for principal diagnoses of adverse effect of medications (ICD-9-CM E-code 930.00-947.9). MAIN OUTCOME MEASURES: Weighted measures of prevalence, nature, demographics, and resource use associated with visits related to adverse effects of medications. RESULTS: An estimated 2.01 million (95% confidence interval, 1.69 to 2.34 million) visits for medication-related morbidity were made to office-based physicians in the United States during 1995, representing an annual rate of 7.70 visits per 1,000 persons. Medication-related visit rates were greater in women, in patients between 65 and 74 years of age, and in the Midwest. The most frequently cited reasons for medication-related visits were skin rash, nausea, and shortness of breath. The therapeutic agents responsible for medication-related visits were most often hormone and synthetic substitutes (13.32%), antibiotics (11.55%), and cardiovascular drugs (9.30%). Medication-related visits most often involved diagnostic services and medication therapy. The majority included instructions for a scheduled follow-up, and fewer than 1% resulted in hospital admission. CONCLUSION: Medication-related ambulatory care utilization can pose a significant burden on health care resources unless specific strategies are initiated to control medication-related problems. The provision of pharmaceutical care can play an important role in reducing medication-related problems and associated health care costs.     

Emergency department care for victims of sexual offense.

PURPOSE: Emergency department (ED) care for sexual offense victims was studied and compared with national treatment guidelines. METHODS: This retrospective study analyzed data from the 2003 National Hospital Ambulatory Medical Care Survey. ED visits were selected based on the reason for the patient's visit, diagnosis, and cause of visit. ED visits were evaluated as two subgroups: rape or sexual assault and molestation or other sexual offense. Data were analyzed to determine whether certain screening procedures were performed, including pregnancy testing, HIV serology testing, urinalysis, cervical or urethral culture, and urine culture. Medication codes for each patient visit were examined to determine if antibiotics, antiretrovirals, emergency contraceptives, anxiolytics, analgesics, or antiemetics were provided. RESULTS: In 2003, there were 251,762 ED visits for a sexual offense; 179,149 of these were for sexual assault or rape and 72,613 for molestation or other sexual offense. Nearly 70% of visits did not involve the prescribing of antibiotic therapy, and during only 6.7% of visits was appropriate antibiotic prophylaxis, as recommended by the Centers for Disease Control and Prevention, provided. For female victims age 12 years or older, pregnancy tests were performed during 36.7% of visits for sexual assault or rape and 6.7% of visits for molestation or other sex crimes. Only 13% of sexual assault or rape victims received HIV serology testing. Sufficient care was provided during only 20.4% of all visits for sexual offense victims. CONCLUSION: The majority of victims of a sexual offense in the United States in 2003 did not receive sufficient care in the ED in accordance with national treatment guidelines.     

Assessing the structure and process for providing pharmaceutical care in Veterans Affairs medical centers.

The structure and process used in providing pharmaceutical care to ambulatory care patients at nine Veterans Affairs medical centers (VAMCs) were studied. Institutions participating in the IMPROVE (Impact of Managed Pharmaceutical Care on Resource Utilization and Outcomes in Veterans Affairs Medical Centers) study were selected. To assess the level of pharmaceutical care services provided to ambulatory care patients, 10 critical domains were identified. Six instruments with questions related to each domain were then designed, including a clinical pharmacist survey and an outpatient pharmacist survey. Each center was assessed through three surveys and an onsite visit. The investigators used both direct observation and a consensus approach to score the level of ambulatory care pharmaceutical services provided. The clinics in which IMPROVE study patients would be seen were run by pharmacists (33%), physicians (44%), and multidisciplinary teams (22%). Of the 51 clinical pharmacists surveyed, 23 (45%) had prescribing authority via protocols, 14 (28%) had unrestricted prescribing privileges, and 14 did not have prescribing authority. The sites varied greatly in referral patterns, methods of identifying patients, and whether patient visits were scheduled or on a walk-in basis. There was a strong correlation between observed activities by clinical pharmacists and their self-reports and between observed activities by outpatient pharmacists and their self-reports. Activities reported by clinical pharmacists were moderately but not significantly correlated with consensus scores, and activities reported by outpatient pharmacists were poorly correlated with consensus scores. The structure and process for providing pharmaceutical care to ambulatory care patients at VAMCs were evaluated with surveys, direct observation, and a consensus-based scoring system.