INTRODUCTION: Pain is common in cancer. Pain can present at the time of diagnosis or it can develop during treatment. Cancer-related chronic pain is often treated with long-term (3 or more consecutive refills) opioid prescriptions. Opioids are a controlled substance and are thus regulated at the federal, state, and local levels. OBJECTIVES: The first goal of this study is to examine Boston Children's Hospital's general compliance with federal, state, and local opioid prescribing policies. The second goal of this study is to distinguish cancer patients requiring long-term opioids from non-cancer patients requiring long-term opioids. METHODS: This study was a retrospective chart review using summative qualitative content analysis. This is the process where content is grouped into themes and then is further quantified within each theme. RESULTS: Documents required to ensure compliance with opioid prescribing regulations at the local level are not always well documented. These include the Long-Term Opioid Agreement and the risk evaluation of opioid misuse and abuse using one of several tools annually. At Boston Children's Hospital (BCH), the CRAFFT (car, relax, alone, forget, friends, trouble) questionnaires are used for this purpose. State policies require that, if a patient is not seen at least once every 6 months, physicians must document explicitly why a clinic visit was not possible. These reasons are never clearly listed within the medical record. Additionally, data shows that cancer patients using long-term opioids tend to be younger (mean age 14.4) than non-cancer patients (mean age 26.7). Cancer pain can present either at diagnosis, during treatment, or be present during both. Where n=16 cancer patients, 62.53% experienced pain both at diagnosis and during treatment, 25% experienced pain only during treatment, and 12.5% experience pain only at diagnosis. Finally, data also show that anxiety and comorbidity are common, 34.6% of n=29 patients in both cancer and non-cancer patients using long-term opioids. 34.6% of patients experienced comorbidities of either anxiety or depression. CONCLUSIONS: Despite these discrepancies with documentation, review of patients on long-term opioids revealed those with complex and painful medical conditions generally had valid reasons to require long-term opioids. Therefore, there is no evidence that BCH prescribers are involved in any sort of inappropriate opioid prescribing. Finally, no meaningful conclusions were drawn from data regarding pain score and weight because of inconsistencies in electronic medical record documentation in these areas.

Non-medical prescribers make an increasing contribution to healthcare across the UK yet little is known about influences on their prescribing decision-making. The aim of this programme of research was to explore and describe prescribing decision-making by non-medical prescribers. A two stage programme of research was carried out. Stage 1 was a systematic review of the social and cognitive influences on prescribing decision-making by non-medical prescribers. Despite a paucity of research, various influences on prescribing decision-making were reported including evidence based guidelines, peer support and patient (or parental) relationships and expectations. While confidence and clinical experience as a practitioner were cited as influences, the lack of prescribing experience and aspects of pharmacological knowledge also impacted on prescribing decision-making, resulting in a cautious approach. Stage 2 of the research employed a phenomenological methodology underpinned by the Theoretical Domains Framework of behavioural determinants (TDF). It comprised three phases. In Phase 1, semi-structured interviews with five nurse prescribers and eight pharmacist prescribers in NHS Grampian explored their experiences and perceptions of influences on their prescribing decision-making, and the impact of these influences. Multiple and sometimes contradictory influences were uncovered. Twelve of the fourteen domains of the TDF were found to be influential along with multi-disciplinary working and experience; optimism and reinforcement did not feature. In Phase 2, these participants recorded reflections on prescribing decisions which they considered noteworthy in relation to their practice, and in Phase 3 participants were interviewed about their reflections. Complexity was a feature of many, in the patients’ clinical or social circumstances or in relation to wider concerns. The same 12 domains were found to be influential as were multi-disciplinary working, experience and complexity. This programme of research has produced original findings which it is hoped will impact on the education, training and practice of these increasingly important prescribers.

Clinical guidelines developed from randomized controlled trials (RCT) recommend standard treatments for physicians to treat their patients. However, RCT are usually conducted among younger or healthier populations. Patients who did not participate in clinical trials, such as the elderly or patients with comorbidities, might not be suitable for the standard treatments; instead non-standard treatments can be an alternative treatment option to provide clinical benefits. Physicians are key stakeholders in determining the use of non-standard treatments in clinical practice. While a number of studies have reported on the use of non-standard treatments, little is known about factors associated with a physician’s decision to use non-standard treatments and which information sources are associated with their use. The objectives of this study were to identify factors associated with a physician’s decision to use non-standard treatments and to investigate which information sources were associated with their use. This study applied Rogers’ theory of diffusion of innovation to posit that a physician’s decisions to use non-standard treatments are a function of 1) the perceived advantages of non-standard treatments (effectiveness and toxicity), 2) the sources of information (scientific sources, professional contacts, patient demands, and commercial sources), 3) physician characteristics (years of practice, specialty, innovativeness, and practice experience), and 4) practice settings (practice location, academic affiliation, types of facility, and practice size). This study implemented a convergent parallel mixed-method approach consisting of interviews and surveys to address the objectives. For this study, a convenience sample of 10 medical oncologists was interviewed in January and February 2017. Interviews were transcribed and coded using a coding system based on the theoretical model of this study. Case reports were created to summarize each interview. The content analysis and multi-case analysis were both conducted to describe variable-level factors and contrast and compare factors within and across groups. Surveys were distributed to 1,500 medical oncologists and hematologists who currently practice in eight states across the Midwest. Dillman’s tailored design method was used to guide survey development and administration. The survey examined oncologists’ use of non-standard treatments in elderly patients with diffuse large B-cell lymphoma (DLBCL). Factorial survey design was applied to construct six hypothetical patient vignettes representing a variety of patient age and comorbidity. The dependent variable was whether a physician recommended a non-standard treatment to each vignette. Independent variables were selected from the theoretical model. The descriptive and frequency statistics were conducted for each survey item. The reliability tests were used to evaluate internal consistency of multi-item measures. Generalized Estimating Equations (GEE) were used to test the influence of factors on a physician’s decisions to use non-standard treatments. Among ten interview participants, three were open and five were intermediate open toward using non-standard treatments. Approximately 41.5% of survey participants recommended non-standard treatments for two or more vignettes. Both interviews and surveys showed that sources of information were key factors affecting oncologists’ use of non-standard treatments. In particular, interviewed oncologists used various information sources to justify their use of non-standard treatments such as early phase clinical trials or colleagues’ suggestions. Survey data showed that oncologists who placed higher importance on scientific sources were less likely to use non-standard treatments although scientific or medical journals were the top sources where they learned about rituximab with non-anthracyclines. In vignettes involving patients with rheumatoid arthritis with chronic neutropenia, those who placed a higher importance of professional sources were more likely to use non-standard treatments. Additionally, interview data showed that oncologists who have a sub-specialty, practice in academic settings, have high patient volume, have positive past experience with non-standard treatment and were aware of colleagues’ use non-standard treatments were relatively more open toward using non-standard treatments. Survey data showed that oncologists who agreed that rituximab with non-anthracyclines has a safer toxicity profile than rituximab with anthracyclines, those who commonly encounter younger patients, and those who had more years since graduating from medical school were more likely to use non-standard treatments. In addition to patient characteristics such as comorbidity, physicians’ characteristics and their sources of information are influential to the decision of using non-standard treatments.

This cross-sectional study used a weighted sample of ED visits contained in the 2010-2015 years of the National Hospital Ambulatory Care Survey-Emergency Department (NHAMCS-ED) dataset. The purpose of this study was to: 1) identify differences in predisposing, enabling, and need characteristics, and ED use and medication prescribing characteristics between homeless and nonhomeless ED users; 2) assess the association between housing status and medication prescribing at ED discharge, and identify variables contributing to the disparity in medication prescribing between homeless and nonhomeless ED users; and 3) assess the predisposing, enabling, need, and ED use characteristics that predict medication prescribing at ED discharge among homeless ED users. This research is guided by the Andersen-Gelberg Behavioral Model for Vulnerable Populations. There were a total of 502,614,359 visits to EDs located within a MSA made by homeless and nonhomeless adults 18 years of age and older. About 0.9% of these visits were made by homeless individuals. Age, mental health diagnosis, substance use diagnosis, primary payer, and patient-reported pain differed significantly between homeless and nonhomeless ED users. A significantly greater proportion of homeless ED users arrived to the ED via ambulance, and was seen in the last 72 hours. Homeless ED users tended to have longer ED visits, and ED disposition differed significantly between homeless and nonhomeless ED users. A significantly smaller proportion of homeless ED users were prescribed a medication at ED discharge, and an opioid medication at ED discharge. There was no difference in the likelihood of medication prescribing at ED discharge between homeless and nonhomeless ED users after controlling for predisposing, enabling, need, and ED use characteristics. ED diagnosis was the greatest contributor to the disparity in medication prescribing at ED discharge between homeless and nonhomeless ED users. Among homeless ED users, visits covered by Medicare and other payers were significantly more likely to result in medication prescribing at ED discharge compared to nonhomeless ED users covered by private insurance. Homeless ED users with no substance use condition diagnosis were significantly more likely to be prescribed a medication at ED discharge compared to those with a substance use condition diagnosis.

L'évolution des soins médicaux en milieu hospitalier se caractérise par une intensité accrue des soins et de l'utilisation des médicaments, ces derniers étant de plus en plus nombreux et souvent onéreux. De plus, les personnes âgées, en nombre croissant dans notre société, souffrent fréquemment de pathologies concomitantes et nécessitent donc une polythérapie. Il devient dès lors de plus en plus complexe d'assurer un usage optimal (efficace, non toxique, et économique) des médicaments, et également d'assurer un suivi adéquat du traitement lorsque ces patients sont transférés entre milieux de soins aigus et chroniques. De nombreuses publications ont mis en évidence, à l'étranger, une prévalence élevée d'utilisation inappropriée des médicaments en gériatrie (sous forme d'overuse, de misuse, et d'underuse). Les facteurs explicatifs d'une utilisation inappropriée n'ont cependant jamais été étudiés dans cette population. Or, cette étape d'identification est indispensable pour le développement d'interventions appropriées. Elle a donc constitué la première partie du travail de recherche (1). Ensuite, certaines études ont tenté d'évaluer l'impact de diverses approches permettant d'améliorer la prescription (y compris la pharmacie clinique), mais peu ont utilisé une méthodologie robuste. De plus, l'intérêt de cette approche de pharmacie clinique n'a jamais été évaluée en Belgique, alors qu'il existe un potentiel certain pour la développer. C'est dans ce cadre que s'est effectuée la deuxième partie du travail (2). (1) Pour répondre au premier objectif, une étude qualitative combinant des données issues d'entretiens et d'observations avec des professionnels et patients au sein de services de gériatrie a été réalisée. Trois grandes catégories de facteurs sous-jacents à une utilisation inappropriée des médicaments ont été identifiés : référence au modèle de soins de santé aigus pour des adultes en général ; attitude d'apprentissage passive; prise de décisions paternaliste. A l'inverse la prise en charge par un gériatre et la communication multidisciplinaire permettent une meilleure utilisation des médicaments. Les mesures d'optimisation potentielles devraient donc entre autres concerner les compétences individuelles, les relations médecin-patient et médecin-médecin, et les systèmes de transfert d'informations entre milieux de soins. (2) Afin de quantifier la qualité de prescription, et l'impact d'une collaboration avec un pharmacien clinicien, une étude randomisée contrôlée a été réalisé, et a inclus 200 patients hospitalisés au sein d'un service de gériatrie. Les résultats montrent que l'intervention d'un pharmacien clinicien permet de réduire de façon significative l'overuse, l'underuse et le misuse des médicaments. L'acceptation des interventions est excellente, et leur pertinence clinique élevée.Enfin, l'intervention s'accompagne d'une tendance à une diminution de la mortalité et de la morbidité des patients, un an après leur sortie de l'hôpital. Ce travail démontre donc l'intérêt de la pharmacie clinique dans le contexte belge, et ouvre plusieurs perspectives, dont une évaluation de la généralisation à d'autres services cliniques, et une évaluation de son rapport coût-efficacité.

Aims: To introduce the concepts “quality assurance”, “rational drug prescribing” and “outreach visits” in general practice in Storstrøm County, Denmark and study the effect of unsolicited mailed feedback and outreach visits on drug prescribing. Methods: The first step was to generate standardised charts displaying the county variations of drug volume prescribing within 13 major drug groups at the second ATC-level. The charts were mailed unsolicited to the 94 general practices in the county. Each practice could identify its position within the county prescribing variation. This procedure was repeated every six months from 1992 to 1998. In 1998 annual outreach visit were offered to general practice and 88 of 94 practices accepted. The awareness of prescribing profiles was monitored during the visits in 1998 and 1999. In 2000 a randomised controlled trial allocating practices into two parallel arms was launched. Effects of two desk guides on rational drug prescribing promoted during outreach visits were evaluated. Results: During the period of mailed feedback, there was a large variation in drug prescribing volumes between practices but little within-practice variation over time. No significant change was detected. Practitioners’ assessment of their own prescribing profiles improved significantly through the outreach visits. The prescribing of antibiotics was significantly affected by the desk guide whereas no effect was detected on the prescribing of non-steroid anti-inflammatory drugs. Conclusions: Semi-annually mailed feedback over a seven-year period had no significant effect on prescribing volumes or variations in prescribing volumes, but some effect on the practitioners’ awareness of their own prescribing profiles. Outreach visits significantly improved the awareness. A randomised controlled trial using outreach visits combined with a simple desk guide affected the prescribing of some antibacterial drugs as intended whereas the similar intervention had no detectable effect on the prescribing of non-steroid anti-inflammatory drugs.

Abstract This research aims to study the current situation of the community pharmacists¡¦ services, such as the collaboration mode with hospitals and medical institutes corresponding to the ¡§Separation of Prescribing and Dispensing¡¨ (Separation of P&D) in Taiwan and prescription dispensing policies, the service orientation, and the operation results in Kaohsiung City, where the Separation of P&D was implemented as early as March 1997. Furthermore, this research also aims to understand the cognition of the community pharmacists upon Pharmaceutical Services and their service orientation. It was discovered from 67 effective samples that the amount of prescriptions dispensed to those registered National Health Insurance (NHI) pharmacies were still few, hence the current situation of Separation of P&D is not that satisfying. In addition, the amount of prescriptions dispensed to community pharmacies joining the NHI were significantly more than those who did not join. Moreover, as far as for those registered NHI pharmacies collaborating with hospitals and medical institutes are concerned, the opportunity for them to receive prescriptions is far from those registered NHI pharmacies that did not collaborate with hospitals and medical institutes. The amount of prescriptions dispensed has a significant and positive correlation to the increasing of pharmacy business. In light of this, it can be said that the collaboration mode between registered NHI pharmacies and hospitals and medical institutes helps with the implementation of the Separation of P&D. The cognition of pharmacist¡¦s practicing can be divided into five categories according to factor analysis, and they are; ¡§Health Maintaining¡¨, ¡§Health Enhancing¡¨, ¡§Pharmaceutical Professional Service¡¨, ¡§Pharmaceuticals Management ¡¨, and ¡§Specialists Consultation¡¨. This research discovered that when the practicing credential is a pharmacist instead of pharmaceutical student, the service cognition on health maintaining, health enhancing, pharmaceutical professional service, and specialist¡¦s consultation were significantly different. The cognition of a pharmacist upon health enhancing and pharmaceuticals control showed significant and positive correlation to his/her business volume. Although the Separation of P&D has been implemented for over six years, and most of the regions in this country have conformed to the P&D separation regulations and the business has been carried out, the outcomes have not met the expectation, and the medicine circle alone cannot solve such problem. It needs a comprehensive consideration and review to effectively implement the existing policies.

published_or_final_version / Medical Sciences / Master / Master of Medical Sciences

Background: Inappropriate use of medications (IUM), in particular inappropriate prescribing and non-adherence to prescribed medications, are important causes of drug-related morbidities (DRMs). They are increasing problems with the ageing populations and the growing burden of chronic conditions. However, research is needed on the association of IUMs with DRMs in outpatient settings and in the general population. Aim: The aim of this thesis is to estimate and analyse the burden of potentially inappropriate prescriptions (PIPs) in the elderly and non-adherence to long-term medications among adults across care settings, and to investigate how IUM is associated to DRMs. Methods: A meta-analysis summarised the previous evidence on the percentage of adverse drug reactions (ADRs) associated to IUM across healthcare settings (Study I). From a cohort in the general population, using medical records and register data, the prevalence of PIPs in the elderly and its association with ADRs were estimated retrospectively (Study II). From the same cohort, the factors associated with refill non-adherence to antihypertensive therapy, considering the use of multiple medications, and the association between non-adherence and sub-therapeutic effects (STEs) were investigated (Study III). A survey assessed the refill behaviour to antihypertensive, lipid lowering and oral antidiabetic medications (undersupply, adequate supply and oversupply), and its association with perceived ADRs and STEs (Study IV). Results: IUM was the cause 52% and 45% of ADRs occurring in adult outpatients and inpatients respectively. Across healthcare settings, 46% of the elderly refilled PIPs over a 6-month period; PIPs were considered the cause of 30% of all ADRs; and the elderly who were prescribed PIPs had increased odds to experience ADRs (OR 2.47, 95% CI 1.65-3.69). In total, 35% was nonadherent to the full multidrug therapy and 13% was non-adherent to any medication (complete non-adherence).  Sociodemographic factors (working age and lower income) were associated with non-adherence to any medication, while clinical factors (use of specialised care, use of multiple medications, and being a new user) with non-adherence to the full multidrug therapy. STEs were associated with non-adherence to any medication a month prior to a healthcare visit (OR 3.27, 95% CI 1.27-8.49), but not with long-term measures of non-adherence. Among survey respondents, 22% of the medications were oversupplied and 12% were undersupplied. Inadequate refill behaviour was not associated with reporting ADRs or STEs (p<0.05). Conclusions: A large proportion of ADRs occurring in hospital is caused by IUM, but more knowledge is needed in other settings. PIPs are common in the elderly general population and associated with ADRs. Therefore decreasing PIPs could contribute towards ADR prevention. Considering the use of multiple medications may help to better understand the factors associated with non-adherence to a multidrug therapy for tailoring the interventions to patient needs. Monitoring the adherence prior to a healthcare visit may facilitate interpreting STEs. Yet, the absence of an association between long-term measures of refill non-adherence with clinical and perceived DRMs suggest the need to enhance the knowledge of this association in clinical practice. In summary, this thesis shows a significant potential for improvements of medication use and outcomes.

Με βάση τα στοιχεία σχετικά με την επίδραση των αξιών και τη σημασία τους μας ενδιαφέρει να τις εξετάσουμε ως προς καθοριστικές παραμέτρους της συνταγογραφικής συμπεριφοράς και της τεχνικές επικοινωνίας που χρησιμοποιούν οι εταιρίες για να προσεγγίσουν τους γιατρούς. H φαρμακευτική βιομηχανία σήμερα εστιάζεται κυρίως σε ποσοτικές μετρήσεις και στον αριθμό των ιατρικών επισκεπτών παρά στην αποτελεσματικότητα των επισκέψεών τους. Αυτό ωθεί τους γιατρούς στο να κλείνουν τις πόρτες στους Ι.Ε. Σε άλλους κλάδους βιομηχανιών όπως στις τράπεζες και στην αυτοκινητοβιομηχανία χρησιμοποιούνται ψυχογραφικά χαρακτηριστικά. Ήδη κάποιες φαρμακευτικές εταιρίες όπως η UCB έχουν ήδη αρχίσει να εκμεταλλεύονται αυτά τα εργαλεία μάρκετινγκ. Οι μέθοδοι αυτοί περιλαμβάνουν τη συνταγογραφική συνήθεια των γιατρών, δημογραφικά, τις αξίες των γιατρών τρόπο ζωής και ότι άλλο μπορεί να επηρεάσει τις συνταγογραφική τους συμπεριφορά. / -