INTRODUCTION The deepening process of demographic aging has a significant impact on all areas of the society. With increasing age, the presence of illness, as well as the amount of used drugs increases. The most commonly prescribed drugs are often proton pump inhibitors, which play an irreplaceable role in the treatment of many gastrointestinal diseases. The trend of the overuse of proton pump inhibitors as the main antisecretory drugs is mainly related to their long-term administration in the prophylaxis of concurrent use of gastrotoxic drugs. The aim of this work was to evaluate the rationality of use of proton pump inhibitors including indications, administered dosages and duration of treatment. METHODS The data collected and used in this work are a part of the FIP7 project of the EUROAGEISM H2020 program. The study involved 438 geriatric patients in acute care institutions in Brno, Prague, and Hradec Králové, who were hospitalized between August 2018 and January 2019. The inclusion criteria were age over 65 years and adherence to inclusion criteria of the study. Seniors with severe cognitive impairment (MMSE < 10 points), memory impairment, speech or hearing impairment, patients hospitalized in the intensive care unit and in the terminal stage of the disease were excluded from the study. Data...

Title: Ageing of the population and use of low-dose drug regimens in older patients (ii.) Author: Jana Koleníková Tutor: Assoc. Prof. Daniela Fialová, PharmD, Ph.D. University: Charles University Faculty: Faculty of Pharmacy in Hradec Králové Department: Department of Social and Clinical Pharmacy Introduction: Proportion of seniors in the population is increasing worldwide, therefore rational pharmacotherapy in older adults is more emphasized. The drug pharmacokinetics and pharmacodynamics change in older age due to physiological and pathological changes, but also due to frequent polymorbidity and polypharmacotherapy. The use of certain medicines is therefore considered risky in seniors. For this reason, explicit expert criteria of medications potentially inappropriate in the aged (so called PIMs) have been created in many countries. Considering the fact that seniors were usually not included in randomized controlled trials, information about specific dosing in older adults for many medications is not stated in Summary of Product Characteristics (SmPCs) which provide basic information on effective and safe administration of medicines. The aim of the diploma thesis was to clarify whether in case of PIMs specific information about geriatric dosing is stated in SmPCs, or at least general warnings that...

京都大学 / 0048 / 新制・課程博士 / 博士(医学) / 甲第18676号 / 医博第3948号 / 新制||医||1007(附属図書館) / 31609 / 京都大学大学院医学研究科医学専攻 / (主査)教授 中山 健夫, 教授 川上 浩司, 教授 柳田 素子 / 学位規則第4条第1項該当 / Doctor of Medical Science / Kyoto University / DFAM

Title: Ageing of the population and selected aspects of the rationality of drug prescribing of statins in older age (II.) Author: Martina Pekařová Tutor: Assoc. Prof. Daniela Fialová, PharmDr, Ph.D. University: Charles University Faculty: Faculty of Pharmacy in Hradec Králové Department: Department of Social and Clinical Pharmacy INTRODUCTION: In the geriatric population, cardiovascular diseases based on atherosclerosis rank first place in morbidity and mortality. A positive effect on cardiovascular morbidity can generally reduce overall morbidity, polymorbidity, polypharmacotherapy, and prolong the quality of life of older patients. Statins are often underprescribedin the treatment of ATS heart disease in older age or are underdosed in both primary and secondary prevention. The main goals of the diploma thesis was to analyze the rationality of statin prescription in the Czech population of seniors, assessed in the EuroAgeism H2020 project in three different health care settings (acute, outpatient and community pharmacy settings of health care). The aim was to describe various aspects of rational / irrational statine therapy in patients older than 65 years (choice of drugs, drug combinations, dosing timing, indications according to the degree of CVS risk in seniors, and indications in the presence...

Institution/department: Charles University, Faculty of Pharmacy in Hradec Králové, Department of Social and Clinical Pharmacy Title of diploma thesis: Rationality of benzodiazepine use in older patients Supervisor: Assoc. Prof. Daniela Fialová, PharmDr. Ph.D. Author: Adriana Magátová Introduction: Benzodiazepines are one of the most commonly prescribed potentially inappropriate drugs (PIMs) in geriatric patients in Europe and are responsible for common problems associated with risky drug prescription in older age (eg, cognitive impairment, falls, orthostatic hypotension, drug dependence, and others). Physiological and pathophysiological changes associated with the aging process, as well as frequent polymorbidity and polypharmacotherapy, are associated with more frequent occurrence of drug-related complications in older age. With the growing proportion of geriatric population, the importance of preventing drug complications in older adults increases. The aim of this study was to compare prescribing habits in the use of BZD and in the use of drug combinations with sedative potential and to determine the association of their use with drug-related risks in geriatric patients in community pharmacy practice in Spain (SP) and the Czech Republic (CZ) and in groups of patients assessed in various healthcare settings...

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Trackers is a collection of short stories that attest to the oddities and complexities found even in the non-exotic middle-class American suburbs. The characters in these stories experience disappointments that result from the physical and emotional distancing of families. In "Tokens," a woman's attempts at revenge on her cheating husband are unsatisfying because she ends up feeling more alone than before. In "Trackers," eleven-year old Richard hunts for Bigfoot as he and his family cope with the emotional aftermath of his sister's suicide attempt. In these stories people struggle to maintain normalcy in their lives--sometimes through inappropriate means. When their expectations are destroyed, they are forced to deal not only with specific abandonment, but also the reality that the world around them has no knowledge--let alone appreciation--of their personal struggles or fears. Occasionally, however, some good can come from this realization. In "Camilla," a ten-year-old girl learns that she can depend on her own experiences for strength rather than knowledge borrowed from fantasies inspired by a collection of obituaries. A woman recovering from the loss of a romantic relationship strengthens her bond with her young niece in "Cattywampus," and they are both strengthened by the world they share as women in different stages of self-discovery.

Laboratory testing is necessary when it contributes to the overall clinical management of the patient. Redundant testing, however, is often unnecessary and expensive and contributes to overall reductions in healthcare system efficiency. The purpose of this study is two-fold. First, to evaluate the frequency of ordering duplicate laboratory tests in hospitalized patients and the costs associated with this practice. Second, it was designed to determine if the use of a computerized alert or prompt will reduce the total number of unnecessarily duplicated Acute Hepatitis Profile (AHP) laboratory tests. This two-phase study took place in an inpatient facility that was part of a large tertiary care hospital system in Florida. A retrospective descriptive design was used during Phase 1 was to evaluate six laboratory tests and the frequency of ordering duplicate laboratory tests in hospitalized patients and to determine the associated costs of this practice for a 12-month time period in 2010. A test was considered a duplicate or an unnecessarily repeated test if it followed a previous test of the same type during the patient’s length of stay in the hospital and one in which any change in their values likely would not be clinically significant. A quasi-experimental pre- and post-test design was used during phase 2 was to determine the proportion of duplication of the AHP test before and after the implementation of a computerized alert intervention implemented as part of a system quality improvement process on January 5th, 2011. Data were compared for two 3-month time periods, pre- and post-alert implementation. The AHP test was considered redundant if it followed a previous test of the same type within 15 days of the initial test being final and present in the medical record. In phase 1, including each of the six tests examined, there were a total amount of 53, 351 test ordered, with 10, 375 (19.4%) of these cancelled. Out of the total amount of result final tests iv (n = 42,976), including each of the six tests examined, 4.6-8.7% were redundant. Results of the proportion of duplication of the six selected tests are as follows: AHP 196/2514 (7.8%), Antinuclear Antibody (ANA) 120/2594 (4.6%), B12/Folate level 396/5874 (6.7%), Thyroid Stimulating Hormone (TSH) 1893/21595 (8.7%), Ferritin 384/5171 (7.4%), and Iron/Total iron binding capacity (TIBC) 316/5155 (6.1%). The overall associated yearly cost of redundant testing of these six selected tests was an estimated $419, 218. The largest proportion of redundant tests was the Thyroid Stimulating Hormone level, costing a yearly estimated $300, 987. In Phase 2, prior to introduction of the alert, 674 AHP tests were performed. Of these, 53 (7.9%) were redundant. During the intervention period, 692 AHP tests were performed, of these 18 (2.6%) were redundant. The implementation of the computerized alert was shown to significantly reduce the proportion of AHP tests (Chi-Square: χ2 = df 1, p ≤ 0.001). The differences in the associated costs of duplicated AHP were $5238 dollars in 2010 as compared to $1746 in 2011 post-alert and these differences were significant (Mann Whitney U, Z = -4.04, p ≤ 0.001). Although the proportions of unnecessarily repeated diagnostic tests that were observed during Phase 1 of this study were small, the associated costs could adversely affect hospital revenue and overall healthcare efficiency. The implementation of the AHP computerized alert demonstrated a drop in the proportion of redundant AHP tests and subsequent associated cost savings. It is necessary to perform further research to evaluate computerized alerts on other tests with evidence-based test-specific time intervals, and to determine if such reductions postimplementation of AHP alerts are sustained over time.

BACKGROUND: High-cost healthcare users (HCUs) are patients who use disproportionate healthcare resources compared to their peers. A better understanding of their co-morbidity status, medication use, and healthcare utilization is needed to improve health interventions and policies. OBJECTIVES: We aimed to: (1) synthesize what is known about HCUs and interventions for managing them, (2) characterize how HCUs differ from non-HCUs, and (3) explore the impact of medications and whether prescribing quality contributes to differences in healthcare costs and HCU status development. METHODS: We synthesized what is known about HCUs and used the GRADE framework to evaluate the evidence for interventions designed to improve their health. We conducted retrospective population-based matched cohort and case-control studies of incident older adult HCUs using health administrative data. We examined prescribing and medication costs over the non-HCU to HCU transition period and compared them to non-HCUs. We conducted logistic regression to evaluate associations between HCU status development and the use of high-cost drugs and potentially inappropriate medications. RESULTS: HCU interventions to date have shown inconsistent effects on clinical outcomes and healthcare costs and the overall quality of evidence supporting their efficacy is low. Compared to non-HCUs, HCUs have higher rates of polypharmacy, hospitalization, and mortality. Medications are the highest healthcare cost category in the pre-HCU year and these costs rise nearly 1.7-fold in the HCU year. High-cost drug use increases significantly during the HCU transition period and 3.6% achieve HCU status based on drug costs alone. Use of several potentially inappropriate medications and high-cost drugs significantly increase the odds of HCU development. CONCLUSIONS: Medications can contribute to high-cost healthcare directly through drug costs alone or indirectly through adverse effects on health. Medication optimization interventions and policies to reduce inappropriate medication use and ensure cost-effective medication use are needed to manage high-cost healthcare and prevent HCU development. / Thesis / Doctor of Philosophy (PhD) / High-cost healthcare users (HCUs) are patients who use disproportionate healthcare resources compared to their peers. More research is needed to better understand HCUs to design interventions to improve their health outcomes and costs. In this thesis, we evaluated what previous studies have discovered about HCUs and we used Ontario’s health system data to explore whether the quality of prescribing and medication use in older adults influences their risk of becoming a HCU. We found that current interventions for HCUs have had inconsistent effects on improving health outcomes and costs. We also found two medication-related factors contributing to the risk of becoming an older adult HCU: (1) use of very expensive medications, and (2) use of potentially inappropriate medications where the risk of harm may outweigh potential benefits. Interventions and health policies to optimize the appropriate and cost-effective use of medications are needed to manage high-cost healthcare and prevent HCU development.

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