Addiction: part II. Identification and management of the drug-seeking patient.
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The medications most often implicated in prescription drug abuse are opioid analgesics, sedative-hypnotics and stimulants. Patients with acute or chronic pain, anxiety disorders and attention-deficit disorder are at increased risk of addiction comorbidity. It is important to ask patients about their substance-use history, including alcohol, illicit drugs and prescription drugs. Patients who abuse prescription drugs may exhibit certain patterns, such as escalating use, drug-seeking behavior and doctor shopping. A basic clinical survival skill in situations in which patients exert pressure on the physician to obtain a prescription drug is to say "no" and stick with it. Physicians who overprescribe can be characterized by the four "Ds"-dated, duped, dishonest and disabled. Maintaining a current knowledge base, documenting the decisions that guide the treatment process and seeking consultation are important risk-management strategies that improve clinical care and outcomes. (+info)
Warfarin for stroke prevention still underused in atrial fibrillation: patterns of omission.
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BACKGROUND AND PURPOSE: The value of warfarin in preventing stroke in patients with chronic atrial fibrillation is well established. However, the prevalence of such treatment generally lags behind actual requirements. The aim of this study was to evaluate doctor- and/or patient-related demographic, clinical, and echocardiographic factors that influence decision for warfarin treatment. METHODS: Between 1990 and 1998, 1027 patients were discharged with chronic or persistent atrial fibrillation. This population was composed of (1) patients with cardiac prosthetic valves (n=48), (2) those with increased bleeding risks (n=152), (3) physically or mentally handicapped patients (n=317), and (4) the remaining 510 patients, the main study group who were subjected to thorough statistical analysis for determining factors influencing warfarin use. RESULTS: The respective rates of warfarin use on discharge in the 4 groups were 93.7%, 30.9%, 17.03%, and 59.4% (P=0.001); of the latter, an additional 28.7% were discharged on aspirin. In the main study group, warfarin treatment rates increased with each consecutive triennial period (29.7%, 53.6%, and 77.1%, respectively; P=0.001). Age >80 years, poor command of Hebrew, and being hospitalized in a given medical department emerged as independent variables negatively influencing warfarin use: P=0.0001, OR 0.30 (95% CI 0.17 to 0.55); P=0.02, OR 0.59 (95% CI 0.36 to 0.94); and P=0.0002, OR 0.26 (95% CI 0.12 to 0.52), respectively. In contrast, past history of stroke and availability of echocardiographic information, regardless of the findings, each increased warfarin use (P=0.03, OR 1.95 [95% CI 1.04 to 3.68], and P=0.0001, OR 3.52 [95% CI 2.16 to 5.72], respectively). CONCLUSIONS: Old age, language difficulties, insufficient doctor alertness to warfarin benefit, and patient disability produced reluctance to treat. Warfarin use still lags behind requirements. (+info)
Trends in hospital antimicrobial prescribing after 9 years of stewardship.
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Trends in antibiotic prescribing in Grampian have been monitored prospectively for 11 years from 1986 using computerized ward stock lists and laboratory data relating to all in-patient and out-patient treatments in all Grampian hospitals. The main outcome measures were the number of antibiotics available for routine and restricted use, annual expenditure and defined daily doses (DDDs) of high expenditure antimicrobial agents. An antibiotic committee introduced a policy and formulary in the third year of the study which has had only limited success in controlling prescribing. This report updates the audit from 1992/3 to 1996/7. During this period 22 new antibiotics were considered for inclusion in the hospital formulary. Seventeen, including seven antiretroviral agents, were incorporated, all for restricted use only. Despite this, expenditure on antibiotics has more than trebled since 1986/7 and increased 50% since 1992/3, two-thirds of the latter increase being due to the use of new drugs, namely anti-HIV drugs, lipid amphotericin derivatives and teicoplanin. Big increases in the use of co-amoxiclav, acyclovir, ciprofloxacin and cefotaxime account for the remainder of the increased expenditure. There was an overall increase of 16.9% in DDDs between 1992/3 and 96/7 to 424.0 DDDs/1000 patient days (393.4 DDDs for antibacterials). These findings highlight the current difficulty in controlling prescribing budgets, the increasing use of antibiotics and the consequent increase of antimicrobial-resistant microorganisms. (+info)
Capture-recapture method in the epidemiology of type 2 diabetes: a contribution from the Verona Diabetes Study.
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OBJECTIVE: The present investigation used data from the Verona Diabetes Study to verify a main assumption of the capture-recapture method (source independence) and to characterize the subgroup of known diabetic patients missed by all sources whose number is estimated by the capture-recapture method. RESEARCH DESIGN AND METHODS: The Verona Diabetes Study identified 7,148 type 2 diabetic patients on 31 December 1986 using 3 different sources: family physicians, a diabetes center, and a drug prescription database. Completeness of ascertainment was estimated with traditional methods based on the hypergeometric distribution and with a log-linear model. RESULTS: Identification sources were not independent because the drug prescription database was positively related to family physicians and negatively related to the diabetes center (P < 0.001). Thus, completeness of ascertainment was overestimated (87.5% [95% CI 86.3-88.8]) when using only family physicians and the drug prescription database and underestimated (45.9% [43.9-48.1]) when using only the diabetes center and the drug prescription database. Because of characteristics contributing to variable "catchability" (probability of ascertainment), the estimated proportion of ascertainment increased with increasing time since diagnosis from 65.6% in the first tertile (<6 years) to 91.5% in the third tertile (>12 years); moreover, the ascertainment was estimated to be nearly complete (97.9%) for insulin-treated patients and scanty (28.9%) for diet-treated patients. CONCLUSIONS: Because identification sources are likely to be dependent, the capture-recapture method should be used with caution in diabetes epidemiology and possibly when at least 3 sources are available. The subgroup of diabetic patients whose existence is inferred by this technique likely consists of newly diagnosed patients with mild disease severity. (+info)
Impact of type 1 and type 2 diabetes on patterns and costs of drug prescribing: a population-based study.
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OBJECTIVE: Utilization and costs of prescription drugs were investigated in diabetic and nondiabetic patients. RESEARCH DESIGN AND METHODS: The study was carried out in Tayside, Scotland, U.K. A validated population-based diabetes register was used to identify patients with type 1 and type 2 diabetes, and a database of all prescriptions dispensed in the community was used to investigate drug utilization in 1995. RESULTS: In a population of 406,526, there were 974 (0.2%) with type 1 diabetes and 6,869 (1.7%) with type 2 diabetes. The mean dispensed prescribing rates for all drugs (excluding antidiabetic medication) were higher across all age-groups for diabetic patients. After adjusting for age, patients with type 1 diabetes were 2.07 times (95% CI 2.03-2.11) more likely and patients with type 2 diabetes were 1.70 times (1.69-1.71) more likely to be dispensed a drug item than people without diabetes. This likelihood was increased in every drug category, even those not directly related to diabetes, and the proportion and cost of drug items dispensed to diabetic patients was therefore higher than expected given the prevalence of diabetes. Upon projecting these results to the U.K. population, it was discovered that nearly 8% of the U.K. drug budget (Pound Sterling 350 million) is accounted for by patients with diabetes (90% of that by patients with type 2 diabetes). CONCLUSIONS: This study highlights the increased usage and cost of prescription drugs in diabetes, with type 2 diabetes constituting a particular burden. It was discovered that 1.4% of drug usage in the entire population can be accounted for by the increased prescribing rate of diabetic patients compared with that of nondiabetic patients. (+info)
Adherence to the guidelines of a regional formulary.
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BACKGROUND: Pharmacotherapeutical guidelines, called formularies, have been developed to facilitate effective, efficient and cost-conscious prescribing. Monitoring adherence to such guidelines may be a reasonable way of assessing prescribing practices. OBJECTIVE: The aim of this study was to assess how strictly the GPs participating in our department's registration network adhere to the guidelines of the regional formulary, and which indications and drugs the GPs used. METHODS: This is a descriptive study, concerning 1000 consecutive prescriptions from each of the 17 participating GPs. The third edition of the Groningen formulary (GFIII), published in 1995, was used. If the drug prescribed was advised in the formulary, we considered it to be global adherence. If the indication was mentioned in the formulary, and the drug prescribed was advised for that indication in the formulary, it was considered to be specific adherence. Both the medications prescribed and the health problems registered by the GPs, but not mentioned in the GFIII, were analysed. RESULTS: The 17 000 prescriptions chosen for analysis formed approximately 25% of all prescriptions written by the GPs in 1 year. The indications for only 24 prescriptions (0. 14%) were missing. Among the 17 GPs, the number of different drugs prescribed varied between 167 and 219 per 1000 prescriptions. The global adherence varied from 76 to 89% among the GPs, and the specific adherence varied from 55 to 71%. Of the 17 000 prescriptions, 11 457 (67%) concerned indications mentioned in the GFIII. Prescriptions for indications not mentioned in the GFIII contained 4353 (78.5%) drugs advised in the formulary. Of the 251 medications mentioned in the GFIII, only 15 (6%) were not prescribed. DISCUSSION: The GPs in our study were neither representative, nor were they chosen at random. Their patient population was comparable in age, sex and insurance status. These findings are an example of what level of adherence is obtainable. The formulary covered approximately two-thirds of the indications registered by GPs, and did not contain many unnecessary medications (6%). (+info)
Hospitals do not inform GPs about medication that should be monitored.
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BACKGROUND: General practitioners are now asked to prescribe drugs that, due to possible risks and side effects, had previously been prescribed almost exclusively at hospital. OBJECTIVE: To assess the quality of hospital letters as the key communication between hospitals and GPs. METHOD: Hospital letters examined using a predetermined protocol. RESULTS: Of 224 patients identified who were taking drugs that required regular monitoring, 173 were commenced in hospital. Fewer than one in five (30; 17%) hospital letters indicated that there was a risk associated with the drug or that it should be routinely monitored. Monitoring frequency was identified on only 14 occasions and the majority of letters (129; 74. 6%) did not state who was to be responsible for ongoing monitoring (either GP or hospital). Information was slow to arrive at the practice and, in 12% of cases, the hospital letter had not arrived within 14 days of commencement of medication. CONCLUSION: The information provided in hospital letters is insufficient to allow GPs to put structures in place to monitor drug therapy. (+info)
Evaluation of the effect of performance monitoring and feedback on care process, utilization, and outcome.
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OBJECTIVE: We evaluated a program of performance measurement and monitoring by assessing care process, utilization of services, and outcomes. RESEARCH DESIGN AND METHODS: Information on 63,264 diabetic individuals who were continuously enrolled as members of Kaiser Permanente Southern California from 1 January 1994 to 31 December 1997 was used to evaluate the program. Time trends in testing for glycemic test and control and screening for dyslipidemia, use of lipid-lowering drugs, and microalbuminuria were evaluated as measures of care process. Time trends in hospitalization, outpatient appointments, prescriptions, and laboratory tests were evaluated as measures of utilization. Outcomes were hospitalization for myocardial infarction, ischemic stroke, and lower-limb amputation. RESULTS: Between 1994 and 1997, improvements were evident in the process measures. The mean number of hospitalizations and the mean and median number of outpatients visits did not change. The mean number of laboratory tests increased from 13.2 in 1994 to 23.6 in 1997. The mean number of prescriptions for any medication increased from 19.7 to 24.3. Hospitalization rates for myocardial infarction did not change, but rates increased for ischemic stroke and lower-limb amputation. CONCLUSIONS: Our findings suggest that measurement and monitoring of clinical performance can bring about modest improvements in measures of the processes of care in the absence of financial incentives, centrally driven interventions, and specialty care for all patients. In our setting, process improvements were associated with higher utilization of laboratory services and more prescriptions without an immediate return in terms of lower hospital utilization. (+info)