Inappropriate prescribing for older people admitted to an intermediate-care nursing home unit and hospital wards

Objective

To identify inappropriate prescribing among older patients on admission to and discharge from an intermediate-care nursing home unit and hospital wards, and to compare changes during stay within and between these groups.

Design

Observational study.

Setting and subjects

Altogether 400 community-dwelling people aged ≥ 70 years, on consecutive emergency admittance to hospital wards of internal medicine and orthopaedic surgery, were randomized to an intermediate-care nursing home unit or hospital wards; 290 (157 at the intermediate-care nursing home unit and 133 in hospital wards) were eligible for this sub-study.

Main outcome measures

Prevalence on admission and discharge of potentially inappropriate medications (Norwegian general practice [NORGEP] criteria) and drug–drug interactions; changes during stay.

Results

The mean (SD) age was 84.7 (6.2) years; 71% were women. From admission to discharge, the mean numbers of drugs prescribed per person increased from 6.0 (3.3) to 9.3 (3.8), p < 0.01. The prevalence of potentially inappropriate medications increased from 24% to 35%, p < 0.01; concomitant use of ≥ 3 psychotropic/opioid drugs and drug combinations including non-steroid anti-inflammatory drugs (NSAIDs) increased significantly. Serious drug–drug interactions were scarce both on admission and discharge (0.7%).

Conclusions

Inappropriate prescribing was prevalent among older people acutely admitted to hospital, and the prevalence was not reduced during stay at an intermediate-care nursing home unit specially designed for these patients.Key Words: Acute illness, drug–drug interactions, elderly, general practice, hospital, intermediate care unit, NORGEP screening tool, Norway, potentially inappropriate medicationsOlder people are at increased risk of adverse drug events. Screening tools may identify potentially inappropriate medications. Treatment in intermediate care units may possibly provide an opportunity for reducing inappropriate prescribing.

• Inappropriate prescribing was prevalent among community-dwelling older people on emergency admittance to hospitals in Bergen, Norway.
• Concomitant use of ≥ 3 psychotropic/opioid drugs and drug combinations including non-steroid anti-inflammatory drugs (NSAIDs) increased significantly during stay.
• Serious drug–drug interactions were scarce on admission and discharge.

     

Medication Pain Management in the Elderly: Unique and Underutilized Analgesic Treatment Options

Background

By 2030, the US population of adults aged ≥65 years will increase by >80%, and these adults will account for nearly 20% of the US population. In this population, the decline of multiple physiologic processes and diseases collectively influence treatment options. Physiologic changes, drug–drug interactions resulting from polypharmacy, and drug–disease interactions combine to make elderly patients more sensitive to the adverse events (AEs) associated with medications, all of which must be considered in drug selection.

Objective

This article focuses on select underutilized medication options for analgesia that may provide significant advantages in the elderly population above and beyond commonly prescribed conventional choices.

Methods

We performed a complete review of the literature using the search terms pain management, elderly, opioids, NSAIDs, topical NSAIDs, levorphanol, buprenorphine transdermal, and tapentadol. Databases searched included PubMed, Google Scholar, Ovid, and Athens. Package inserts were utilized for approval dates, indications, and formulations available. We looked at reviews of agents to identify important studies for consideration that searches may have missed. Pharmacology and pharmacokinetic data were taken from randomized trials focusing in this area. Pivotal Phase III trials were utilized for discussion of clinical trial experience and to summarize efficacy and AEs. For purposes of validity, only peer-reviewed literature was included.

Results

There were limited data that specifically outlined analgesic drug selection and highlighted safer alternatives for the elderly patient based on polypharmacy risks, end-organ deterioration, and/or drug choices that presented less risk. We focused on unique opioid alternatives: levorphanol, which offers several therapeutic advantages similar to methadone but without the pharmacokinetic and drug–interaction pitfalls associated with methadone; tapentadol, associated with significantly less gastrointestinal distress and constipation; and transdermal buprenorphine, an agonist/antagonist with less risk for the toxicities associated with conventional opioids and with compliance benefits. Topical NSAIDs are discussed as a viable therapeutic option. Specific attention to a more desirable tolerability profile, including avoidance of drug interactions, end-organ dysfunction, and gastrointestinal bleed with topical NSAID agents versus their oral counterparts is discussed, including the ability to achieve superior tissue levels for appropriately selected inflammatory conditions.

Conclusion

It is incumbent that providers consider these options as part of an analgesic armamentarium in an effort to maximize therapeutic benefit and minimize risks in the increasing elderly patient population.     

Pharmacogenomic Variability of Oral Baclofen Clearance and Clinical Response in Children With Cerebral Palsy

Background

Pharmacogenomic variability can contribute to differences in pharmacokinetics and clinical responses. Pediatric patients with cerebral palsy with genetic variations have not been studied for these potential differences.

Prescribing behaviour after the introduction of decentralized drug budgets: Is there an association with employer and type of care facility?

Objective

To analyse whether prescribing patterns changed after introduction of drug budgets and whether there is an association between drug prescribing patterns and the type of employer and care facility.

Methods

Data analysed encompassed information on dispensed medicines, by workplaces, prescribed in the Region Västra Götaland, Sweden, for the years 2003 and 2006. Workplaces (n = 969) were categorized according to type of employer and type of care facility. Five prescribing indicators reflecting goals for cost-containing prescribing in Region Västra Götaland were assessed. Changes over time and differences between different types of employer and care facility were analysed by Mann–Whitney tests.

Results

In 2003, workplaces with a public employer had a significantly higher adherence to three of the prescribing indicators compared with private practitioners. Two of these differences remained in 2006. In 2003, none of the prescribing indicators differed between primary care and other care facilities. Three years later workplaces in primary care had a significantly higher adherence to three of the prescribing indicators than other care facilities. There was a statistically significant difference in change between 2003 and 2006 between primary care and other care facilities; there were no differences in change between workplaces with public and private employers.

Conclusions

Adherence to three of the prescribing indicators increased after the introduction of decentralized drug budgets. Workplaces with a public employer showed greater adherence to two of the prescribing indicators than private sector workplaces.     

Effect of educational outreach on general practice prescribing of antibiotics and antidepressants: A two-year randomised controlled trial

Objective

Prescribing of broad spectrum antibiotics and antidepressants in general practice often does not accord with guidelines. The aim was to determine the effectiveness of educational outreach in improving the prescribing of selected antibiotics and antidepressants, and whether the effect is sustained for two years.

Design

Single blind randomized trial.

Setting

Twenty-eight general practices in Leicestershire, England.

Intervention

Educational outreach visits were undertaken, tailored to barriers to change, 14 practices receiving visits for reducing selected antibiotics and 14 for improving antidepressant prescribing.

Main outcome measures

Number of items prescribed per 1000 registered patients for amoxicillin with clavulanic acid (co-amoxiclav) and quinolone antibiotics, and average daily quantities per 1000 patients for lofepramine and fluoxetine antidepressants, measured at the practice level for six-month periods over two years.

Results

There was no effect on the prescribing of co-amoxiclav, quinolones, or fluoxetine, but prescribing of lofepramine increased in accordance with the guidelines. The increase persisted throughout two years of follow-up.

Conclusion

A simple, group-level educational outreach intervention, designed to take account of identified barriers to change, can have a modest but sustained effect on prescribing levels. However, outreach is not always effective. The context in which change in prescribing practice is being sought, the views of prescribers concerning the value of the drug, or other unrecognised barriers to change may influence the effectiveness of outreach.     

SCAMPs for Multimodal Post-Operative Analgesia: A Concept to Standardize and Individualize Care

Purpose of Review

We discuss the challenges and strategies in delivering post-operative pain relief that is both standardized and individualized as appropriate. Post-operative pain remains under-treated and is frequently complicated by side effects. Guidelines for multimodal analgesia report varying strengths of evidence. Additionally, there are particular evidence gaps in establishing how individual and population subgroups responses vary, due to pharmacogenetic, metabolic, and psychological variation.

Recent Findings

In cases where evidence is scarce or low quality, Standardized Clinical Assessment and Management Plans (SCAMPs) are an innovative method for healthcare practitioners to integrate available evidence resources and avoid unplanned variations in the quality of care delivered. Implementation of SCAMPs can be facilitated by the sheer volume of relevant information for drug prescribing and monitoring, drug-drug interactions, laboratory tests of organ function, drug metabolism and excretion data, electronic medical record data, and individual pharmacogenetic profile data.

Summary

Standardization of care using algorithms or computer-assisted prescribing is emerging as a useful tool to raise compliance where guidance does exist. Individualizing care may require computational analysis of vast quantities of individual and population data to support or lead clinician decision-making. Such technology is used widely across diverse fields ranging from meteorology and commerce to agriculture and gene sequencing, but there are particular applications and challenges within medicine. To maximize benefit and reduce harm from post-operative analgesia, standardization and individualization, such as SCAMPs must be balanced and employed as appropriate.

     

Associations between the concurrent use of clinical decision support and computerized provider order entry and the rates of appropriate prescribing at discharge

Introduction

Electronic health record systems used in conjunction with clinical decision support (CDS) or computerized provider order entry (CPOE) have shown potential in improving quality of care, yet less is known about the effects of combination use of CDS and CPOE on prescribing rates at discharge.

Objectives

This study investigates the effectiveness of combination use of CDS and CPOE on appropriate drug prescribing rates at discharge for AMI or HF patients.

Methods

Combination use of CDS and CPOE is defined as hospitals self-reporting full implementation across all hospital units of CDS reminders, CDS guidelines, and CPOE. Appropriate prescribing rates of aspirin, ACEI/ARBs, or beta blockers are defined using quality measures from Hospital Compare. Multivariate linear regressions are used to test for differences in mean appropriate prescribing rates between hospitals reporting combination use of CDS and CPOE, compared to those reporting the singular use of one or the other, or the absence of both. Covariates include hospital size, region, and ownership status.

Results

Approximately 10% of the sample reported full implementation of both CDS and CPOE, while 7% and 17% reported full use of only CPOE or only CDS, respectively. Hospitals reporting full use of CDS only reported between 0.2% (95% CI 0.04 – 1.0) and 1.6% (95% CI 0.6 – 2.6) higher appropriate prescribing rates compared to hospitals reporting use of neither system. Rates of prescribing by hospitals reporting full use of both CPOE and CDS did not significantly differ from the control group.

Conclusions

Although associations found between full implementation of CDS and appropriate prescribing rates suggest that clinical decision tools are sufficient compared to basic EHR systems in improving prescribing at discharge, the modest differences raise doubt about the clinical relevance of the findings. Future studies need to continue investigating the causal nature and clinical relevance of these associations.     

Survey of Ontario primary care physicians' experiences with opioid prescribing

Objective

To measure physicians’ experiences with opioid-related adverse events and their perceived level of confidence in their opioid prescribing skills and practices.

Design

Mailed survey.

Setting

The province of Ontario.

Participants

A total of 1000 primary care physicians randomly selected from the College of Physicians and Surgeons of Ontario registration database.

Main outcome measures

Opioid-related adverse events and concerns (eg, number of patients, type of opioid, cause of the event or concern); physicians’ confidence, comfort, and satisfaction with opioid prescribing; physicians’ opinions on strategies to optimize their prescribing; and physicians’ perspectives of their interactions with pharmacists and nurses.

Results

The response rate was close to 66%, for a total of 658 participants. Almost all respondents reported prescribing opioids for chronic pain in the past 3 months. Eighty-six percent of respondents reported being confident in their prescribing of opioids, but 42% of respondents indicated that at least 1 patient had experienced an adverse event related to opioids in the past year, usually involving oxycodone, and 16.3% of respondents did not know if their patients had experienced any opioid-related adverse events. The most commonly cited factors leading to adverse events were that the patient took more than prescribed, the prescribed dose was too high, or the patient took alcohol or sedating drugs with the opioids. Most physicians had concerns about the opioid use of 1 or more of their patients; concerns included running out of opioids early, minimal access to pain and addiction treatment, and addiction and overdose. The reported number of physicians’ patients taking opioids was positively associated with their confidence and comfort levels in opioid prescribing and negatively associated with their belief that many patients become addicted to opioids.

Conclusion

Most physicians have encountered opioid-related adverse events. Comprehensive strategies are required to promote safe prescribing of opioids, including guidelines and comprehensive office-system materials.     

Antibiotic prescribing in nursing homes in an area with low prevalence of antibiotic resistance: compliance with national guidelines

Objective

To examine antibiotic prescribing in nursing homes and determine to what degree the prescribing was in accordance with the national guidelines for antibiotic prescribing.

Design

Retrospective examination of patients’ records who were prescribed antibiotics in the period 1 March 2007 to 28 February 2008.

Setting and patients

Patients residing in the nursing homes of Arendal, Norway.

Main outcome measures

Choice of antibiotic in respect of the recommendations in the national guidelines for antibiotic prescribing.

Results

A total of 714 antibiotic courses were prescribed to 327 patients yielding a prevalence of 6.6%. Compliant prescribing was 77% for urinary tract infections (UTI), 79% for respiratory tract infections (RTI), and 76% for skin and soft tissue infections (SSTI). Ciprofloxacin was responsible for 63% of non-compliant prescribing. On the respite wards there was a higher rate of total prescribing, non-compliant prescribing, and prescribing by physicians employed at the local hospital.

Conclusion

Guidelines for antibiotic use must be implemented actively and efforts to improve antibiotic prescribing in nursing homes must be aimed at both nursing home and hospital physicians.Key Words: Anti-bacterial agents, antibiotic resistance, compliance, geriatrics, infection, nursing homesThe geriatric population has a relatively high use of antibiotics, but few studies document compliance with national guidelines when prescribing antibiotics.

• Compliance with guidelines for urinary tract, respiratory tract, and soft tissue infections was about 80%.
• Ciprofloxacin is the antibiotic responsible for the majority of non-compliant prescribing.
• Non-compliant prescribing and prescribing by physicians not employed at the nursing home is higher on respite wards than on the long-term wards.

     

NSAIDs in the Treatment of Postoperative Pain

Purpose of Review

Postoperative pain results in multiple undesirable physiologic and psychological outcomes, and it should be managed in a multimodal approach. This article reviews the latest scientific literature of NSAIDs in the treatment of postoperative pain. The goal is to answer the following questions: (1) Are NSAIDs effective in the postoperative period? (2) Are NSAIDs safe in all surgical patients? and (3) Are adverse effects of NSAIDs increased or diminished in the acute postoperative period?

Recent Findings

NSAIDs are safe and effective in the treatment of postoperative pain, and they should be administered to all postoperative surgical patients unless contraindicated.

Summary

Based on literature, NSAIDs have been shown to increase patient satisfaction and decrease opioid requirements, minimizing opiate-induced adverse events. They have no increased incidence of adverse effects during the acute postoperative period. NSAIDs and COX-2 inhibitors, however, should be used with caution in colorectal surgery as they are proven to increase the risk of anastomotic leak.

     

Relationship Between Diclofenac Dose and Risk of Gastrointestinal and Cardiovascular Events: Meta-Regression Based on Two Systematic Literature Reviews

Background

NSAIDs are associated with risks of gastrointestinal (GI) and cardiovascular (CV) toxicities. It has been reported that the risks of GI and CV events are dose related, resulting in guidance explicitly emphasizing the use of NSAIDs at the lowest effective dose for the shortest duration. To understand the potential benefits of using lower doses of diclofenac, a more detailed understanding of the relationship of diclofenac dose and the risks of GI and CV events is required.

Objective

The objective of this study was to extend previous research quantifying the NSAID dose–toxicity relationship by modeling dose as a continuous measure, allowing for an assessment of the risks of major GI and CV events for patients taking specific diclofenac doses compared with NSAID nonusers.

Methods

We used studies identified in 2 recently published systematic reviews of observational studies that examined the risks of major GI and CV events associated with the use of oral NSAIDs. We developed meta-regression models, considering dose as a continuous measure, to estimate the risks of major GI and CV events for different daily doses of conventional oral diclofenac relative to nonuse of NSAIDs.

Results

Seven of the 59 GI publications, contributing 11 dose-specific risk ratio observations, and 12 of the 51 CV studies, contributing 21 dose-specific risk ratio observations, were eligible for inclusion in the meta-regression. The models indicated positive linear relationships between diclofenac dose and the relative risks of major GI and CV events for the range of doses examined.

Conclusions

To our knowledge, this is the first study to quantify and aggregate the continuous relationship between the risk of GI or CV events and the dosage of an NSAID. With the recent availability of new low doses of diclofenac, the models may be used to estimate the potential reduction in risk of adverse events at these doses.     

Recommendations for Substance Abuse and Pain Control in Patients with Chronic Pain

Purpose of Review

In the present investigation, current literature on the relationship between substance abuse and pain is evaluated in order to improve clinical management and its implications on the increasingly challenging chronic pain and substance abuse epidemic. The relationship between substance abuse and chronic pain are evaluated, and this review provides recommendations on the management of this special patient population.

Recent Findings

Currently, there are limited guidelines for prescribing opioids and other analgesics in the chronic pain population. As this field of practice continues to evolve, it is essential for clinicians to serve as the gatekeepers to monitor for misuse and safety. Multiple studies have indicated that illicit drug use and opioid abuse affect over 9% of patients. Although there are numerous reasons for seeking illicit drugs and abusing them, it is essential that clinicians identify factors which place certain patients at high risk and accordingly, to screen these patients in order to optimize their management.

Summary

The high prevalence of patients with chronic pain who also screen positive for drug use emphasizes the importance and increasingly pressing need to evaluate and to manage chronic pain in this population.

     

Analgesic Use and Risk for Acute Coronary Events in Patients With Osteoarthritis: A Population-based,Nested Case-control Study

Purpose

Recent controversies on the safety profiles of opioids and paracetamol (acetaminophen) have led to changes in clinical guidance on osteoarthritis (OA) management. We studied the existing association between the use of different OA drug therapies and the risk for acute coronary events.