Physician adherence to recommendations for duration of empiric antibiotic treatment for uncomplicated urinary tract infection in women: a national drug utilization analysis

BACKGROUND: Current guidelines for the empiric treatment of uncomplicated urinary tract infection in women recommend that first-line trimethoprim-sulfamethoxazole (TMP-SMX) or ofloxacin be given for 3 days and nitrofurantoin for 5 days. Increasing the duration of treatment raises costs, and perhaps, the incidence of adverse effects, without contributing to effectiveness. The aim of this study was to investigate physician adherence to these recommendations. METHODS: The electronic patients record system of a nationwide health management organization in Israel was reviewed for all primary care visits by adult women treated empirically for cystitis or urinary tract infection from January 2001 to June 2002 (n = 7738 patient-physician encounters). The proportion of cases treated according to the guidelines, with regard to duration, was calculated for each drug used. RESULTS: Rate of adherence was 3.36% for cases of TMP-SMX treatment (95%CI: 2.56%, 4.15%), 22.23% for nitrofurantoin (95%CI: 19.81%, 24.65%) and 4.08% for ofloxacin (95%CI: 2.88%, 5.28%). The crude rate of adherence for all cases of treatment with these drugs was 8.67% (95%CI: 7.82%, 9.52%). CONCLUSIONS: The high rate of nonadherence observed (91.33%) indicate a need for a remedial education program for physicians to improve empiric treatment of urinary tract infection in women. Since this issue is of global importance, we believe our evaluation can serve as model for other settings and countries.     

A study of adherence to drug recommendations by providing feedback of outpatient prescribing patterns to hospital specialists

PURPOSE: To study the effect of feedback using prescribing profiles combined with interactive group discussions on hospital specialists' adherence to evidence-based guidelines for drug treatment of common diseases issued by a regional Drug and Therapeutics Committee. METHODS: Intervention study performed at 17 clinics at a university hospital in a Swedish metropolitan health region with comparative clinics at a second university hospital as a control. Prescribing profiles based on aggregate pharmacy dispensing data were presented for the physicians in interactive group discussions. Deviations from the guidelines were discussed at each clinic and specific goals of improvement were formulated. The effect was assessed by pre- and post-intervention comparison of the adherence to guidelines for all drugs and within 11 selected therapeutic areas. The credibility and usefulness of the prescribing profiles were evaluated by a questionnaire. RESULTS: The adherence to pharmaceutical products within the pharmacological groups stated in the guideline increased by 2.8%-units at the intervention hospital compared with 0.8%-units at the control hospital. The adherence to drug substance increased by 0.4%-units at the intervention hospital while it decreased by 1.8%-units at the control hospital. For 8 of 11 pre-defined specific goals of improvement, the change in adherence was more positive at the intervention hospital. Most doctors considered the feedback provided clear and relevant. CONCLUSIONS: Interactive group discussions with prescribing profiles were found to be useful in improving hospital specialists' adherence to guidelines. However, the effect on the overall adherence was modest, indicating the importance of clear messages for improvement and relevant guidelines for the prescribing of specialist drugs but also more precise methods for evaluating the effect of real-life-interventions.     

Use of lipid-lowering drugs from 1990 to 1994: an international comparison among Australia, Finland, Italy (Emilia Romagna Region), Norway and Sweden

Objective: To compare the overall utilisation patterns of lipid-lowering drugs between 1990 and 1994 in Australia, Finland, Italy, Norway and Sweden as well as the pattern of use with respect to age and gender in Italy and Sweden. Methods: Data were retrieved from regulatory authorities in each country for the 5-year period and analysed according to the ATC/DDD methodology (Anatomical Therapeutic Chemical classification/Defined Daily Doses). Utilisation was calculated as the DDDs for 1000 inhabitants per day for all drugs of the ATC category B04 (serum lipid-reducing agents). Data from Sweden and Italy were also compared with respect to gender and age. Results: In 1994, Australia demonstrated the highest degree of utilisation (11.9 DDD) and the Nordic Countries the lowest (Sweden 5.6; Norway 4.9; Finland 4.0). In all countries except Italy, a steady increase was observed; in Italy, utilisation of these drugs reached a maximum in 1992 (11.5 DDD), but then underwent a reduction which was caused by restrictions in the reimbursement status in 1993 (10.4) and 1994 (6.7). Administration of statins increased in all countries, becoming the most used group of the B04 class. In 1988, the number of different drugs listed by each national health service ranged from 4 (Norway) to 16 (Italy); in 1994 it ranged from 6 (Norway) to 9 (Sweden). Analysis with respect to gender showed the opposite pattern in Sweden (males 4.6 and females 3.3 in 1992; 6.2 and 4.5, respectively, in 1994) than in Italy (males 10.8 and females 17.8 in 1992; 6.4 and 9.2, respectively, in 1994). Exposure was highest in people aged 60–69 years in both countries, followed by age group 50–59 in Sweden and 70–79 in Italy. Conclusions: Large variations in the utilisation of lipid-lowering drugs exist between countries, with Australia and Italy much higher than others. Of the drugs in the ATC category B04, the use of statins predominates in all countries, but to varying degrees. The large difference in the degree of drug utilisation with respect to age and gender between Italy and Sweden suggests major deviations from evidence-based medicine. Received: 12 February 1997 / Accepted in revised form: 6 March 1997     

An overview of the patterns of prescription opioid use,costs and related harms in Australia

AimsTo report Australian population trends in subsidized prescribed opioid use, total costs to the Australian government to subsidize these medicines and opioid-related harms based on hospitalizations and accidental poisoning deaths.MethodsWe utilized three national aggregated data sources including dispensing claims from the Pharmaceutical Benefits Scheme, opioid-related hospitalizations from the National Hospital Morbidity Database and accidental poisoning deaths from the Australian Bureau of Statistics.ResultsBetween 1992 and 2012, opioid dispensing episodes increased 15-fold (500 000 to 7.5 million) and the corresponding cost to the Australian government increased 32-fold ($8.5 million to $271 million). Opioid-related harms also increased. Opioid-related hospitalizations increased from 605 to 1464 cases (1998–2009), outnumbering hospitalizations due to heroin poisonings since 2001. Deaths due to accidental poisoning (pharmaceutical opioids and illicit substances combined) increased from 151 to 266 (2002–2011), resulting in a rise in the death rate of 0.78 to 1.19 deaths/100 000 population over 10 years. Death rates increased 1.8 fold in males and 1.4 fold in females.ConclusionsThe striking increase in opioid use and related harms in Australia is consistent with trends observed in other jurisdictions. Further, there is no evidence to suggest these increases are plateauing. There is currently limited evidence in Australia about individual patterns of opioid use and the associated risk of adverse events. Further research should focus on these important issues so as to provide important evidence supporting effective change in policy and practice.     

A systematic review of the impact of alcohol use disorders on HIV treatment outcomes, adherence to antiretroviral therapy and health care utilization

Background

Alcohol use disorders (AUDs) are highly prevalent and associated with non-adherence to antiretroviral therapy, decreased health care utilization and poor HIV treatment outcomes among HIV-infected individuals.

Objectives

To systematically review studies assessing the impact of AUDs on: (1) medication adherence, (2) health care utilization and (3) biological treatment outcomes among people living with HIV/AIDS (PLWHA).

Data sources

Six electronic databases and Google Scholar were queried for articles published in English, French and Spanish from 1988 to 2010. Selected references from primary articles were also examined.

Review methods

Selection criteria included: (1) AUD and adherence (N = 20); (2) AUD and health services utilization (N = 11); or (3) AUD with CD4 count or HIV-1 RNA treatment outcomes (N = 10). Reviews, animal studies, non-peer reviewed documents and ongoing studies with unpublished data were excluded. Studies that did not differentiate HIV+ from HIV− status and those that did not distinguish between drug and alcohol use were also excluded. Data were extracted, appraised and summarized.

Data synthesis and conclusions

Our findings consistently support an association between AUDs and decreased adherence to antiretroviral therapy and poor HIV treatment outcomes among HIV-infected individuals. Their effect on health care utilization, however, was variable.     

Consistency of assessment of adverse drug reactions in psychiatric hospitals: A comparison of an algorithmic and an empirical approach

Summary Within an ongoing drug surveillance project (AMÜP) in psychiatric hospitals, a comparative study was carried out to evaluate two methods commonly used in the field of adverse drug reaction assessment. Two raters, who have cooperated with the project since its inception, evaluated 80 randomly selected ADRs twice; first, by an empirical (implicit) approach, and second, 4 weeks later, by using an algorithm as proposed by Kramer et al. 1979. Agreement on medication and related probability ratings was obtained in 81% of all 80 cases for the empirical method (weighted Kappa=0.41), and in 69% for the algorithmic method (weighted Kappa=0.62), indicating that agreement exceeded chance for both methods. By comparison with assessments made in previous case conferences of the project, empirical ratings were found to be reliable over time due to homogeneous use of criteria by project raters. In contrast to the reports on the subject, agreement between raters appeared to be superior in the empirical method as compared to the algorithmic assessment. Analysis of disagreements suggested that probability ratings based on the empirical method were nonspecific, due to conventional criteria applied in the project. Inter-rater agreement was reduced by polypharmacy, especially in the case of algorithmic assessments. The consistency of assessment was also lowered by the fact that the 2 methods assigned different weights to particular assessment criteria.Dedicated to Prof. Dr. H. Kewitz, Head of the Department of Clinical Pharmacology, Klinikum Steglitz, Berlin (West), on the occasion of his 65th birthday     

用ABC法分析新疆医科大学附属中医医院肿瘤科2008-2009年药物利用情况

目的:调查新疆医科大学附属中医医院肿瘤科药物利用情况,为临床合理用药提供参考。方法:采用ABC法对肿瘤科2008年和2009年所用的药品进行统计分析,确定A类药品的分布,并对A类中成药和抗肿瘤药按用药金额排序。结果:2009年药品用药金额较2008年上升0.66%,分类结构份额无明显变化。A类中成药用药金额两年均位居第一,以中药注射剂为主,抗肿瘤药位居第二。2009年的抗肿瘤药、免疫调节剂、抗微生物药物、循环系统用药、镇痛药、呼吸系统用药和激素类药所占比例较2008年有所增加,消化系统用药、影响骨代谢药、维生素和微量元素营养药较2008年有所减少,血液系统用药所占比例无明显变化。结论:本院肿瘤科药物利用存在一些不合理现象,需要加强管理。