Polypharmacy and inappropriate prescriptions are prominent prescribing issues with elderly patients. Beers criteria and other guidelines have been developed to assist in the reduction of potentially inappropriate medications prescribed to elderly patients. The objectives of this study were to assess the prescribing pattern for elderly Nigerian outpatients and estimate the prevalence of potentially inappropriate medications among them using the Beers criteria.
This was a prospective cross-sectional study of elderly patients (65 years and above) who were attending the general outpatients clinic of a rural Nigerian hospital. For the drug utilization aspect of the study, drug-use indicators were assessed using established World Health Organization guidelines, while the Beers criteria was used to screen for potentially inappropriate medications.
The medical records of 220 patients aged 65 years and above were utilized for the study. A total of 837 drugs were prescribed for the patients, giving an average of 3.8 ± 1.3 drugs per person. Antihypertensive drugs accounted for 30.6% of the prescriptions, followed by multivitamins/food supplements (11.5%) and analgesics (10.8%). A review of the prescribed medications using the 2012 Updated Beers Criteria by the American Geriatric Society identified 56 patients with at least one potentially inappropriate medication prescribed giving a rate of 25.5%. The drug groups identified were nonsteroidal anti-inflammatory drugs, antihistamines, and amitriptyline.
Polypharmacy and prescription of potentially inappropriate medications are major therapeutic issues in Nigeria. There is a need for prescriber training and retraining with emphasis on the geriatric population.
drug utilization pattern; elderly patients; rational use of medicines; adverse drug reactions; Beers criteria
An audit of two practices in 1987 revealed a wide range of antibiotic prescribing for acute sore throat among the general practitioners. The data were presented at a postgraduate meeting and recommendations were made for a practice policy on antibiotic prescribing. The results of studies that looked at the objectives of treatment were included at that meeting. This paper presents a re-evaluation of the same doctors' antibiotic prescribing one-year later. Changes had occurred in the range and costs of drugs chosen, but individual doctors' prescribing rates remained broadly similar, in other words it was easier to influence what, but not whether, a doctor prescribes for this clinical condition. The existence of a prescribing 'threshold' within the individual doctor is supported.
Spirometry is a cost-effective diagnostic tool for evaluation of lung function and for case-finding in a resource-limited setting. The acceptance of this test depends on the awareness of its indications and the ability to interpret the results. No studies have assessed the knowledge of spirometry among Nigerian doctors. The aim of this study was to evaluate the current knowledge, awareness and practice of spirometry among hospital-based Nigerian doctors.
We carried out a cross-sectional survey among 321 doctors working in Nigerian hospitals between March 2008 and June 2008. Information on knowledge, awareness, practice of and barriers to spirometry were obtained using a pre-tested, self-administered structured questionnaire and the data were then analysed.
Of the 321 doctors that participated, 108 (33.6%) reported that they have good knowledge of spirometry. One hundred and ninety-five (60.7%) were aware of the importance of spirometry in aiding the diagnosis of respiratory diseases; 213(66.4%) were aware of the importance of spirometry in determining the severity of diseases. Medical school was the most common source of knowledge on spirometry (64.5%). Eighty-one (25.2%) doctors reported having a spirometer in their hospitals. Doctors having access to a spirometer used it more frequently for aiding the diagnosis of COPD (40.7% vs.27.5%) and for monitoring of asthma (18.5% vs.11.3%) than those without access to a spirometer. The doctors working in University Teaching Hospitals and Federal Medical Centres (FMC) (22.4% vs. 4.5%) and those having access to a spirometer (40.7 vs.11.3%) were very confident of interpreting spirometry results compared to those working in District and General Hospitals and without access to a spirometer. Irrespective of access to a spirometer or the type of hospital they were employed in, doctors reported that unavailability of a spirometer was the greatest barrier to its use (62.5%) followed by lack of awareness about its usefulness (17.2%).
The knowledge and practice of spirometry were poor among hospital-based Nigerian doctors because of unavailability of spirometers in most hospitals. These findings have implications for further evaluation, planning and management of patient care in respiratory disease. Spirometers should be made available in all hospitals, and the knowledge of spirometry should be improved among doctors.
OBJECTIVES--To determine the patterns of preventive to reactive prescribing for asthma among general practices in the City and East London Family Health Services Authority area and their relation to prescribing cost. DESIGN--Descriptive study of asthma prescribing during April 1992 to March 1993. Prescribing data were linked with general practice and population data on one database. SETTING--City and East London Family Health Services Authority area, including all general practices in contract with the authority, which covers the inner city London Boroughs of Hackney, Tower Hamlets, and Newham and the Corporation of the City of London. SUBJECTS--All 163 general practices as at 1 June 1993. MAIN OUTCOME MEASURES--Ratios of prescribed inhaled corticosteroids plus cromoglycates (prophylactic treatment) to bronchodilators; distribution of the cost of asthma prescribing; distribution of overall generic prescribing; proportion of asthma generic prescribing; distribution of cost of overall drugs prescribed per prescribing unit. RESULTS--Practices approved for band 3 health promotion or asthma surveillance and those with a general practitioner trainer had on average higher ratios of prophylactic to bronchodilator treatment and significantly higher asthma drug costs than other practices. Those practices with high levels of overall generic prescribing had significantly higher prophylactic to bronchodilator ratios than those with lower levels of generic prescribing. Practices with higher levels of asthma drug generic prescribing also had significantly higher prophylactic prescribing. However, the proportion of generically prescribed asthma drugs was lower than overall generic prescribing. There was no correlation between the ratio of prophylactic to bronchodilator asthma prescribing and the proportion of overall drugs expenditure, but high spending practices spent significantly more on asthma drugs. CONCLUSIONS--Pressure to reduce the cost of asthma prescribing may lead to a lowering of the ratio of prophylactic to bronchodilator treatments. However, reducing prophylactic prescribing would run contrary to the British Thoracic Society guidelines and might worsen the quality of asthma care.
This nationwide study was conducted to assess the extent of adherence of primary-care physicians to the World Health Organization (WHO)-recommended guidelines on the use of oral rehydration therapy (ORT), antimicrobials, and prescribing of other drugs used in treating symptoms of acute diarrhoea in Bahrain. A questionnaire-based, cross-sectional survey was carried out in primary-care health centres. During a six-week survey period (15 August–30 September 2003), 328 (25.2%) completed questionnaires were returned from 17 of 20 health centres. In a sample of 300 patients, oral rehydration salts (ORS) solution was prescribed to 89.3% (n=268) patients; 12.3% received ORS alone, whereas 77% received ORS in combination with symptomatic drugs. Antimicrobials were prescribed to 2% of the patients. In 11.4% of the cases, rehydration fluids and other drugs were given parenterally. The mean number of drugs was 2.2+0.87 per prescription. In approximately one-third of the patients, three or more drugs were used. Primary-care physicians almost always adhered to the WHO guidelines with respect to ORT and antimicrobials. However, in several instances, ORT was prescribed along with polypharmacy, including irrational use of drugs for symptomatic relief. Effective health policies are needed to reduce the unnecessary burden on the healthcare system.
Compliance; Cross-sectional studies; Diarrhoea, Acute; Drug therapy; Oral rehydration solutions; Oral rehydration therapy; Bahrain
BACKGROUND: The assessment of prescribing performance by aggregated measures mainly developed from automated databases is often helpful for general practitioners. For asthma treatment, the frequently applied ratio of anti-inflammatory to bronchodilator drugs may, however, be misleading if the specificity of a drug for the treatment of asthma, compared with other diseases, is unknown. AIM: To test the association of specific drugs with the diagnosis of asthma compared with other diagnoses. DESIGN OF STUDY: Cross-sectional study analysing prescription data from a retrospective chart review. SETTING: Eight general practices and one community respiratory practice in a town in Northern Germany. METHOD: All patients in the participating practices who received at least one of the 50 asthma drugs most frequently prescribed in Germany within the past 12 weeks were identified. Odds ratios (ORs) with 95% confidence intervals (ClI) were calculated to reveal any association between a specific drug and the diagnosis of asthma. The unit of analysis was the item prescribed. RESULTS: Topical betamimetics (e.g salbutamol, fenoterol) were the most often prescribed asthma drugs in the general practices (52.1 ) and in the respiratory practice (57.6%). Inhaled steroids accounted for 15% and 13%; systemic steroids accounted for 10% and 13%, respectively. In the general practices, inhaled betamimetics had a moderate marker function for asthma (OR = 2.0; 95% CI = 1.14-3.58). A fixed oral combination drug of clenbuterol plus ambroxol was a marker drug against asthma (OR = 0.35; 95% CI = 0.20-0.61). In the respiratory practice, the diagnosis of asthma was strongly marked by fixed combinations of cromoglycate plus betamimetics (OR = 29.0; 95% CI = 6.86-122.24) and moderately by inhaled betamimetics (OR = 2.6; 95% CI = 1.28-5.14). In contrast, systemic steroids (OR = 0.24; 95% CI 0.10-0.57) and even inhaled steroids (OR = 0.46; 95% ClI= 0.22-0.96) proved to contradict the diagnosis of asthma. CONCLUSION: Only betamimetics were markers for asthma patients in both types of practices; inhaled steroids, however, were not. Combinations of cromoglycate were markers in the respiratory practice only. Limited specificity of drugs for a disease (e.g asthma) should be taken into account when analysing prescribing data that are not diagnosis linked.
US national guidelines recommend assessing short-acting β-agonist (SABA) medication use as a marker of asthma severity and control. However, the relationship between recent SABA use and asthma exacerbations is not currently known.
To evaluate the proximal relationship between the type and frequency of SABA use and asthma-related outcomes.
We evaluated SABA use among patients with asthma ages 5 to 56 years who were members of a large health maintenance organization in southeast Michigan. Frequency of use was estimated from pharmacy data assessing the timing and amount of SABA fills. Cox proportional hazards models were used to examine the prospective relationship between average daily SABA use for 3 months and outcomes associated with poor asthma control (ie, oral corticosteroids use, asthma-related emergency department visits, and asthma-related hospitalizations). We separately accounted for SABA metered-dose inhaler (MDI) and SABA nebulizer use.
Of the 2,056 patients who met study criteria, 1,569 (76.3%) had used a SABA medication in their baseline year. After adjusting for potential confounders, SABA nebulizer use was associated with asthma-related emergency department visits (adjusted hazard ratio [aHR], 6.32; 95% confidence interval [CI], 2.38 to 16.80) and asthma-related hospitalizations (aHR, 21.62; 95% CI, 3.17 to 147.57). In contrast, frequency of SABA MDI use was not associated with these outcomes.
Frequency of SABA use during a 3-month period was associated with poor asthma outcomes. The relationship with poor asthma outcomes was strongest for SABA nebulizer use, suggesting that the type of SABA used is also of prognostic importance.
The role of asthma controller medication adherence and the level of asthma control in children is poorly defined.
To assess the association between asthma controller medication adherence and asthma control in children using routinely acquired prescribing data.
A retrospective observational study of children aged 0–18 years prescribed inhaled corticosteroids only (ICS), leukotriene receptors antagonists (LTRA), or long-acting β2 agonists (LABA) and ICS prescribed as separate or combined inhalers, between 01/09/2001 and 31/08/2006, registered with primary care practices contributing to the Practice Team Information database. The medication possession ratio (MPR) was calculated and associations with asthma control explored. Poor asthma control was defined as the issue of prescriptions for ≥1 course of oral corticosteroids (OCS) and/or ≥6 short-acting β2 agonists (SABA) canisters annually.
A total of 3172 children prescribed asthma controller medication were identified. Of these, 15–39% (depending on controller medication) demonstrated adequate MPR. Adequate MPR was associated with male gender, good socio-economic status, and oral LTRA therapy. Adequate MPR was more likely to be associated with increased use of rescue medication. However logistic regression only identified a significant relationship for ICS only (odds ratio [OR], 1.89; 95% confidence interval [CI], 1.35–2.48; p<0.001), LTRA (OR, 2.11; 95% CI, 1.27–3.48; p = 0.004) and LABA/ICS (OR, 2.85; 95% CI, 1.62–5.02; p<0.001).
Poor adherence was observed for all asthma controller medications, although was significantly better for oral LRTA. In this study adequate adherence was not associated with the use of less rescue medication, suggesting that adherence is a complex issue.
Background—It is difficult to put research findings into clinical practice by either guidelines or prescription feedback.
Aim—To study the effect on the quality of prescribing by a combined intervention of providing individual feedback and deriving quality criteria using guideline recommendations in peer review groups.
Methods—199 general practitioners in 32 groups were randomised to participate in peer review meetings related to either asthma or urinary tract infections. The dispensing by the participating doctors of antiasthmatic drugs and antibiotics during the year before the intervention period provided the basis for prescription feedback. The intervention feedback was designed to describe the treatment given in relation to recommendations in the national guidelines. In each group the doctors agreed on quality criteria for their own treatment of the corresponding diseases based on these recommendations. Comparison of their prescription feedback with their own quality criteria gave each doctor the proportion of acceptable and unacceptable treatments.
Main outcome measure—Difference in the prescribing behaviour between the year before and the year after the intervention.
Results—Before intervention the mean proportions of acceptably treated asthma patients in the asthma group and urinary tract infection (control) group were 28% and 27%, respectively. The mean proportion of acceptably treated patients in the asthma group was increased by 6% relative to the control group; this difference was statistically significant. The mean proportions of acceptable treatments of urinary tract infection before intervention in the urinary tract infection group and asthma (control) group were 12% for both groups which increased by 13% in the urinary tract infection group relative to the control group. Relative to the mean pre-intervention values this represented an improvement in treatment of 21% in the asthma group and 108% in the urinary tract infection group.
Conclusions—Deriving quality criteria of prescribing by discussing guideline recommendations gave the doctors a basis for judging their treatment of individual patients as acceptable or unacceptable. Presented with feedback on their own prescribing, they learned what they did right and wrong. This provided a foundation for improvement and the process thus instigated resulted in the doctors providing better quality patient care.
Key Words: quality assessment; quality improvement; prescription feedback; continuing medical education; asthma; urinary tract infection
To assess the use of asthma drugs by men and women with asthma and to identify sex specific predictors for the use of oral steroids.
Cross sectional study.
Six general practices in East Anglia.
103 men and 134 women aged 20-54 with asthma.
Main outcome measures
Self reported use of β agonists, inhaled steroids, and oral steroids.
No sex difference was found in use of β agonists or inhaled steroids. However a strong association existed between sex and oral steroid use. 40 (30%) women reported using oral steroids compared with nine (9%) men. Women were more than five times (odds ratio=5.5, 95% confidence interval 2.2 to 13.7) more likely to report use of oral steroids than men after asthma symptoms, age, visits to the general practitioner in previous six months, and time since diagnosis of asthma were controlled for. Women who had visited the general practitioner for asthma one or more times in the previous six months were four times (3.9, 1.6 to 9.5) as likely to report use of oral steroids. In addition, more frequent visits to the general practitioner for asthma were related in a dose-response manner to a greater likelihood of using oral steroids among women after asthma symptoms, age, and time since diagnosis were controlled for. This relation was not observed among men.
Women used oral steroids more than men. The more frequent consultations with a doctor by women may result in more requests for oral steroids or doctors may preferentially prescribe oral steroids to women.
Key messagesWomen tend to take more prescription drugs than menIn this study men and women reported similar use of β agonists and inhaled steroids for asthma but women used significantly more oral steroidsWomen who had visited their general practitioner for asthma in the past six months were four times more likely to take oral steroids than those who had not visitedA dose-response relation was found between number of visits to the general practitioner and use of oral steroidsWomen may be making more requests for steroids or doctors may be preferentially prescribing them to women
To assess the relationship between prescription asthma inhaler misuse and other substance abuse.
The study included a random sample of 5th through 10th grade students attending one, ethnically diverse school district in metropolitan Detroit (N =1017). A cross-sectional, web-based survey design was used. The survey included questions about the use and misuse of prescribed asthma inhalers (among other medications) as well as the use of alcohol, cigarettes, marijuana, and other drugs. We investigated four types of interaction with prescribed asthma inhalers: non-use, prescribed use, prescribed use and misuse, and misuse.
Students who misused asthma inhaler medication during their lifetimes were more likely to smoke cigarettes and marijuana as well as more likely to drink alcohol, binge drink and have used other illicit drugs. Students who used asthma inhaler medication solely as prescribed were no more likely to abuse drugs or alcohol than non-users of prescription asthma inhalers.
Our findings are of interest to clinicians who provide health care to adolescents. The present study also has implications for adults managing prescription asthma medication in households and schools.
Asthma inhaler abuse and diversion; Drug abuse; Prescription drug abuse
Despite reductions in morbidity and mortality and changes in guidelines, little is known regarding changes in asthma treatment patterns.
To examine national trends in the office-based treatment of asthma between 1997 and 2009.
PARTICIPANTS AND DESIGN
We used the National Ambulatory Care Survey (NAMCS) and the National Disease and Therapeutic Index™ (NDTI), nationally representative audits of office-based physicians, to examine patients diagnosed with asthma less than 50 years of age.
Visits where asthma was diagnosed and use of six therapeutic classes (short-acting β2 agonists [SABA], long-acting β2 -agonists [LABA], inhaled steroids, antileukotrienes, anticholinergics, and xanthines).
Estimates from NAMCS indicated modest increases in the number of annual asthma visits from 9.9 million [M] in 1997 to 10.3M during 2008; estimates from the NDTI suggested more gradual continuous increases from 8.7M in 1997 to 12.6M during 2009. NAMCS estimates indicated declines in use of SABAs (from 80% of treatment visits in 1997 to 71% in 2008), increased inhaled steroid use (24% in 1997 to 33% in 2008), increased use of fixed dose LABA/steroid combinations (0% in 1997 to 19% in 2008), and increased leukotriene use (9% in 1997 to 24% in 2008). The ratio of controller to total asthma medication use increased from 0.5 (1997) to a peak of 0.7 (2004). In 2008, anticholinergics, xanthines, and LABA use without concomitant steroids accounted for fewer than 4% of all treatment visits. Estimates from NDTI corroborated these trends.
Changes in office-based treatment, including increased inhaled steroid use and increased combined steroid/long-acting β2-agonist use coincide with reductions in asthma morbidity and mortality that have been demonstrated over the same period. Xanthines, anticholinergics, and increasingly, LABA without concomitant steroid use, account for a very small fraction of all asthma treatments.
primary care; respiratory disease; pharmacotherapy
We investigated the withdrawal of temazepam in a single general practice using two alternative prescribing policies: an alternative benzodiazepine; or an alternative group of drugs recommended for short-term management of insomnia, including sedative antihistamines and chloral hydrate. The study showed that temazepam prescribing in general practice can be reduced or stopped by using a simple intervention. An alternative benzodiazepine is useful in helping patients to stop their use of hypnotic agents. The use of antihistamines as substitute hypnotics is not advocated on the basis of our findings.
OBJECTIVES--To survey current prescribing practice for hormone replacement therapy among general practitioners and to elicit their views on the role of hormone replacement therapy in the prevention of osteoporosis and cardiovascular disease; to determine whether they would participate in randomised controlled trials to evaluate the long term beneficial and adverse effects of hormone replacement therapy. DESIGN--Postal questionnaires to general practitioners throughout the United Kingdom. PARTICIPANTS--1268 general practitioners in the Medical Research Council's general practice research framework. RESULTS--1081 (85%) doctors in 220 (95%) practices responded. The doctors were currently prescribing hormone replacement therapy to an estimated 9% of their female patients aged 40 to 64, and 55% of doctors were prescribing opposed hormone replacement therapy (oestrogen plus progestogen) to more patients than a year previously. Over half the doctors would consider prescribing hormone replacement therapy for prevention of osteoporosis (670, 62%) and cardiovascular disease (611, 57%) to asymptomatic women. Overall, 79% of the doctors (851) would definitely or probably consider entering women who have had a hysterectomy into a randomised controlled trial comparing unopposed (oestrogen only) hormone replacement therapy with opposed hormone replacement therapy; 49% (524) would enter patients with a uterus into such a trial. Among a subsample, 85% (180/210) would consider entering patients without menopausal symptoms into a trial comparing hormone replacement therapy with no treatment (unopposed in patients who have had a hysterectomy, opposed in those with a uterus). CONCLUSION--There is considerable uncertainty among general practitioners as to the balance of beneficial and harmful effects of hormone replacement therapy in the long term, particularly relating to its use for prevention of osteoporosis and cardiovascular disease. Most of these doctors would be prepared to participate in randomised controlled trials to determine the long term effects of this increasingly widely used treatment.
In this part of the study we intended to determine (a) the extent to which currently supplied information was used by general practitioners to assess their performance and (b) the preferences of the doctors for new information. Four aspects of professional activity were investigated: prescribing, practice activity as shown by family practitioner committee quarterly returns, hospital use, and audit in depth. The results are from 508(76%) questionnaires returned from the 669 general practitioners circulated in Leicestershire and Lincolnshire. The prescribing habits of most doctors are influenced both by factual information about drugs from many sources and by feedback on their personal prescribing or that of their practice, which is supplied by the Prescription Pricing Authority, particularly regarding prescribing costs. Little use is made of data from the family practitioner committee. A distinct pattern of preferences for particular items of information emerged. Most doctors wished to receive information that would enable them to compare their personal performance or that of their practice with their local colleagues from the Prescription Pricing Authority (66%), the family practitioner committee (58%), and hospital sources (57%). Because doctors chose particular items of information that they would like to have, systems that are developed to provide such information are likely to be used. The need to incorporate comparison with peers is particularly important.
The adoption of new medicines is influenced by a complex set of social processes that have been widely examined in terms of individual prescribers’ information-seeking and decision-making behaviour. However, quantitative, population-wide analyses of how long it takes for new healthcare practices to become part of mainstream practice are rare.
We applied a Bass diffusion model to monthly prescription volumes of 103 often-prescribed drugs in Australia (monthly time series data totalling 803 million prescriptions between 1992 and 2010), to determine the distribution of adoption rates. Our aim was to test the utility of applying the Bass diffusion model to national-scale prescribing volumes.
The Bass diffusion model was fitted to the adoption of a broad cross-section of drugs using national monthly prescription volumes from Australia (median R2 = 0.97, interquartile range 0.95 to 0.99). The median time to adoption was 8.2 years (IQR 4.9 to 12.1). The model distinguished two classes of prescribing patterns – those where adoption appeared to be driven mostly by external forces (19 drugs) and those driven mostly by social contagion (84 drugs). Those driven more prominently by internal forces were found to have shorter adoption times (p = 0.02 in a non-parametric analysis of variance by ranks).
The Bass diffusion model may be used to retrospectively represent the patterns of adoption exhibited in prescription volumes in Australia, and distinguishes between adoption driven primarily by external forces such as regulation, or internal forces such as social contagion. The eight-year delay between the introduction of a new medicine and the adoption of the prescribing practice suggests the presence of system inertia in Australian prescribing practices.
Adoption; Diffusion of innovation; Decision-making; Prescribing behaviour; Australia; Evidence-based practice
Observations in the UK at the end of the last century found increasing trends of asthma prevalence over time. However, it has been reported that the number of new cases of asthma presenting to general practice has declined, especially among younger children.
To study national trends in the epidemiology of asthma.
A cross-sectional observation analysis was performed using the QRESEARCH database, which is one of the world's largest national aggregated health databases containing records from 422 English practices yielding 30 million patient-years of observation. Data was extracted on 333,294 individuals with a recorded diagnosis of asthma and calculated annual age–sex standardized incidence, lifetime period prevalence and asthma-related prescribing rates for each year from 2001–2005.
The incidence rate of asthma decreased in all patients (2001: 6.9 (95% confidence intervals [CI] 6.8–7.0); 2005: 5.2 (95% CI 5.1–5.3) per 1000 patient-years, p<0.001), but most particularly in children under 5 years of age (–38.4%) where a decrease in the lifetime prevalence of asthma (–34.3%) was also found. However, the lifetime prevalence rate of asthma for adults increased (15–44 years: 23.3%; 45–64 years: 27.7%; >65 years: 21.5%) with an estimated 5,658,900 (95% CI 5,639,700–5,678,200) or approximately one person in nine having being diagnosed with asthma in England. The number of asthma-related prescriptions also increased over the study period (17.1%), such that in 2005 an estimated 32,577,300 (95%CI 32,531,600–32,623,000) prescriptions were issued.
This large national study reveals that the rate of new diagnoses of asthma appears to have passed its peak; however, the number of adults with a lifetime asthma diagnosis continues to rise. Whether these trends are genuine or are a result of the introduction of incentives and guidelines to improve identification and recording of asthma or changing diagnostic trends is a question with important public health implications and one, therefore, that warrants detailed further enquiry.
OBJECTIVE--To determine the prevalence of continuous use of oral steroids in the general population, the conditions for which they are prescribed, and the extent to which patients taking oral steroids are taking treatment to prevent osteoporosis. DESIGN--A cross sectional study with a four year retrospective review of drug treatment. SETTING--Eight large general practices in central and southern Nottinghamshire. SUBJECTS--A population of 65,786 patients (52% women) registered with a general practitioner during 1995. RESULTS--303 patients (65% (197) women) aged 12-94 years were currently taking "continuous" (for at least three months) oral corticosteroid treatment. This figure represents 0.5% of the total population and 1.4% (245/17 114) of patients aged 55 years or more (1.7% (166/9601) of women). The usual steroid was prednisolone (97% (294/303)), the mean dose was 8.0 mg/day, and the median duration of oral steroid treatment determined in 149 patients was three years. The most common conditions for which continuous oral steroids were prescribed were rheumatoid arthritis (23% (70)), polymyalgia rheumatica (22% (66)), and asthma or chronic obstructive airways disease (19% (59)). Only 41 (14%) of the 303 patients taking oral steroids had received treatment for the prevention of osteoporosis over the past four years. Although 37 of the 41 patients were women, only 10% (18/181) of the women over 45 years taking continuous oral corticosteroids were currently taking hormone replacement therapy. CONCLUSIONS--If our figures are typical then they suggest that over 250,000 people in the United Kingdom are taking continuous oral steroids and that most of these are taking no prophylaxis against osteoporosis.
Paediatric asthma best practice not only includes prescribing the correct therapeutic mix based on consensus guidelines, but also reducing therapy once control has been achieved. Clinicians should also be aware that asthma in young children is a heterogeneous entity, and a beneficial response to bronchodilators and/or inhaled steroids is not inevitable. In general, preschool children and infants should not be prescribed inhaled corticosteroids above 200 µg beclometasone dipropionate equivalent twice a day, or regular oral steroids, or long acting ß2-adrenoceptor agonists. New therapies such as anti-IgE antibodies are on the horizon, but these are unlikely to replace the established drug combinations. More likely is that the delivery of established drugs will become more convenient (for example, once a day inhaled corticosteroids, or season dependent prophylactic therapy).
Despite the advances in asthma therapeutics, there are few data on the use and determinants of anti-asthmatic drugs in the general population of children. This study describes the use of asthma medications among children in the general population and in children with current asthma, living in a large urban center in Brazil.
A population-based cross-sectional survey, aimed at analyzing asthma determinants, was conducted with 1,382 children aged 4–11 years, between February and May 2006, in Salvador, Brazil. At baseline, an extensive questionnaire was applied, including questions about the use of asthma medications in the last 12 months.
In all studied children (n = 1,382) aged 4–11 years, oral beta2-agonists were the drugs most frequently used (9.8%), followed by short-acting inhaled beta2-agonists (4.3%) and systemic corticosteroids (1.6%). Anti-asthmatic drug use was higher among males than females, and it significantly decreased with age in both genders. A total of 312 children (22.6%) reported current asthma, and 62% of them were not being treated with any anti-asthmatic drugs. Of all those who reported following a certain type of treatment, 20% used oral beta2-agonists alone; 6.1%, short-acting inhaled beta2-agonists alone; and 4.8%, a combination of both drugs. Anti-asthmatic drug use did not differ according to socioeconomic status, except for the use of inhaled beta2-agonists and systemic corticosteroids.
An overwhelming majority of asthmatic children were not using long-term medications for asthma, in particular inhaled corticosteroids, regardless of the severity of their disease. This result points to the deficiencies of the Brazilian public health system in recognizing this important pharmacological need for child care and thereby limiting the access of these children to a group of efficacious, available, and low risk therapeutic medications.
Asthma; Pharmacoepidemiology; Asthma; Therapy; Children; Prevalence; Cross-sectional studies; Brazil
In developing these international guidelines there were several unifying themes in the diagnosis and simple management of childhood asthma. For the purposes of the meeting, asthma was operationally defined as 'episodic wheeze and/or cough in a clinical setting where asthma is likely and other rarer conditions have been excluded'. In making a diagnosis of asthma, a full history is a prerequisite. Additional tests are only used to support clinical impression and to provide objective evidence for therapeutic recommendations. General features of a multidisciplinary approach include an appreciation of the importance of psychosocial factors, counselling, and education. Drugs should be prescribed in a rational sequence: beta 2-stimulants for mild episodic wheeze; sodium cromoglycate for mild to moderate asthma; inhaled steroids for moderate to severe asthma; with xanthines, ipratropium bromide, and oral steroids having their place in more persistent and severe cases. Children and their parents should be reassured that if asthma is properly controlled there is no reason why the child should not lead a normal and physically active life. The management of asthma is rewarding and return to 'normal' lifestyle is nearly always possible with active participation in sporting activities.
Buprenorphine is a safe, effective and underutilized treatment for opioid dependence that requires special credentialing, known as a waiver, to prescribe in the United States.
To describe buprenorphine clinical practices and barriers among office-based physicians.
Two hundred thirty-five office-based physicians waivered to prescribe buprenorphine in Massachusetts.
Questionnaires mailed to all waivered physicians in Massachusetts in October and November 2005 included questions on medical specialty, practice setting, clinical practices, and barriers to prescribing. Logistic regression analyses were used to identify factors associated with prescribing.
Prescribers were 66% of respondents and prescribed to a median of ten patients. Clinical practices included mandatory counseling (79%), drug screening (82%), observed induction (57%), linkage to methadone maintenance (40%), and storing buprenorphine notes separate from other medical records (33%). Most non-prescribers (54%) reported they would prescribe if barriers were reduced. Being a primary care physician compared to a psychiatrist (AOR: 3.02; 95% CI: 1.48–6.18) and solo practice only compared to group practice (AOR: 3.01; 95% CI: 1.23–7.35) were associated with prescribing, while reporting low patient demand (AOR: 0.043, 95% CI: 0.009–0.21) and insufficient institutional support (AOR: 0.37; 95% CI: 0.15–0.89) were associated with not prescribing.
Capacity for increased buprenorphine prescribing exists among physicians who have already obtained a waiver to prescribe. Increased efforts to link waivered physicians with opioid-dependent patients and initiatives to improve institutional support may mitigate barriers to buprenorphine treatment. Several guideline-driven practices have been widely adopted, such as adjunctive counseling and monitoring patients with drug screening.
opioid dependence; buprenorphine; medication assisted treatment
Asthma management guidelines recommend a stepwise approach to instituting and adjusting anti-inflammatory controller therapy for children with asthma. The objective of this retrospective observational study was to describe prescribing patterns of asthma controller therapies for children in a primary care setting.
Data from the UK General Practice Research Database were examined for children with recorded asthma or recurrent wheezing who, from September 2006 through February 2007, were ≤ 14 years old at the time of a first asthma controller prescription after ≥ 6 months without a controller prescription. We evaluated demographic characteristics, asthma duration, comorbidities, asthma-related health care resource use, and prescribed daily dose of controller medication. In addition, physicians for 635 randomly selected patients completed a survey retrospectively classifying asthma severity at the prescription date and describing therapy and health care utilization for 6 prior months.
We identified 10,004 children, 5942 (59.4%) of them boys, of mean (SD) age of 8.0 (3.8) years. Asthma controller prescriptions were for inhaled corticosteroid (ICS) monotherapy for 9059 (90.6%) children; ICS plus long-acting β2-agonist (LABA) for 698 (7.0%); leukotriene antagonist monotherapy for 91 (0.9%); ICS plus leukotriene antagonist for 55 (0.6%); and other therapy for 101 (1.0%), including 45 (0.45%) children who were prescribed LABA as monotherapy. High doses of ICS (> 400 μg) were prescribed for 44/2140 (2.1%) children < 5 years old and for 420/7452 (5.6%) children ≥ 5 years. Physicians reported asthma severity as intermittent for 346/635 (55%) patients and as mild, moderate, and severe persistent for 159 (25%), 71 (11%), and 11 (2%), respectively (severity data missing for 48 [8%]). The baseline characteristics and controller therapy prescriptions of the survey cohort were similar to those of the full cohort.
Physician classifications of asthma severity did not always correspond to guideline recommendations, as leukotriene receptor antagonists were rarely used and high-dose ICS or add-on LABA was prescribed even in intermittent and mild disease. In UK primary care, monotherapy with ICS is the most common controller therapy at all levels of asthma severity.
A long-acting β2-agonist (LABA) combined with an inhaled corticosteroid (ICS) is frequently prescribed as initial therapy in steroid-naïve asthma patients because of its effective control of symptoms and improvement of pulmonary function. However, it is unclear which patients will be responsive to LABAs and whether bronchial responsiveness to LABAs is similar to that to short-acting β2-agonists (SABAs) in a clinical setting. Therefore, the goal of the present study was to compare the changes in spirometric parameters after SABA (salbutamol) inhalation to those after 1-month LABA/ICS (salmeterol/fluticasone propionate) therapy. Spirometric changes were evaluated as absolute values, as the percentage of predicted normal values and as the percentage of baseline values after salbutamol inhalation or 1-month LABA/ICS therapy in 45 patients with asthma. Compared to SABA inhalation, LABA/ICS therapy produced significant improvements in forced expiratory volume in 1 sec (FEV1), peak expiratory flow (PEF), forced expiratory flow at 50% of vital capacity expired (FEF50%) from baseline (expressed as the percentage predicted) in all patients. FEV1 and the FEV1/forced vital capacity (FVC) ratio after SABA or LABA/ICS therapy were inversely related to the corresponding baseline values. Analysis of spirometric changes after SABA inhalation showed that FEV1 was the best among spirometric parameters, such as PEF, correlated with responsiveness to LABA/ICS therapy. Reversibility of FEV1 with SABA inhalation predicts the spirometric response to LABA/ICS as initial therapy in patients with bronchial asthma. LABA/ICS therapy had a greater effect on bronchial reversibility in asthmatic patients, compared to SABA inhalation. This suggested that evaluation of bronchial reversibility after LABA/ICS therapy would be superior to that after SABA inhalation.
bronchial asthma; short-acting β2-agonist; long-acting β2-agonist; bronchial reversibility; lung function test
Studying drug use pattern among medical practitioners is of vital importance in the present scenario where irrational drug use and development of drug resistance is becoming rampant.
To assess, the pattern of prescribing practices among the general practitioners in a defined rural and urban area of Tamil Nadu.
Materials and Methods:
A community based descriptive study was conducted to collect 600 prescriptions from the catchment areas of rural and urban health training centers of a medical college using prescribing indicators as per the WHO “How to investigate drug use in health facilities” tool.
This prescription study revealed that multivitamins (19.5%), antibiotics (19.3%), drugs for gastro-intestinal tract (GIT) (18%), analgesic non-steroidal anti-inflammatory drugs/ (NSAID's) (15.1%), and antihistaminic (12.5%) were prescribed frequently. Among the antibiotics, amoxicillin (49.2%) was the most commonly prescribed followed by gentamicin (31.7%). Percentage of prescriptions with an antibiotic was 55% and nearly 62% of the practitioners prescribed drugs by their generic names. As a practice of poly-pharmacy, it was observed that the average number of drugs prescribed in urban and rural area was nearly 5 and 4, respectively. Nearly 80% of the urban and rural practitioners were prescribing at least one injection. Study of the quality of prescriptions revealed that there was poor legibility, high usage of abbreviations, inadequate details of the drugs, and absence of signature by practitioners in the prescriptions.
This study clearly highlights the practice of poly-pharmacy, low usage of generic drugs, injudicious usage of antibiotics and injections and low usage of drugs prescribed from essential drugs list.
Drug prescriptions; essential drugs; general practitioners; inappropriate prescribing; primary care physicians