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PubMed2006

Prescription of beta-blockers in patients with advanced heart failure and preserved left ventricular ejection fraction. Clinical implications and survival.

BACKGROUND: The effects of beta-blockers in patients with heart failure (HF) and preserved left ventricular ejection fraction (LVEF) are not well established. AIMS: To assess the association between beta-blocker prescription at discharge and mortality in a cohort of patients with advanced HF and preserved LVEF. METHODS AND RESULTS: We prospectively studied a cohort of 443 patients with advanced HF and preserved LVEF (LVEF> or =40%). Mean age was 78 years, 56% female, 33% NYHA class IV. Overall, 227 patients (51%) had a beta-blocker prescribed at discharge. Mean duration of follow-up was 25 (+/-18) months. Death (all cause) occurred in 40 patients (17.6%) who were receiving a beta-blocker at discharge and 73 patients (33.8%) who were not on a beta-blocker. In multivariate Cox analysis, including adjustment for propensity score, prescription of a beta-blocker remained associated with a 43% relative mortality risk reduction (HR 0.57, 95% CI 0.37 to 0.88, p=0.01). CONCLUSIONS: In this cohort of patients with advanced HF and preserved LVEF, prescription of a beta-blocker was associated with a significant mortality reduction. This beneficial effect of beta-blocker use needs to be further confirmed in prospective, randomised clinical trials.

Adrenergic beta-Antagonists↗
PubMed2005

Nonmedical use of prescription opioids among teenagers in the United States: trends and correlates.

PURPOSE: This article reports on trends and correlates of the nonmedical use of prescription opioids among youth. METHODS: Secondary analyses of data from the National Survey on Drug Use and Health were performed on youths, ages 12 to 17. RESULTS: Analyses revealed evidence of an emerging epidemic of opioid misuse among teenagers. Sub-groups of youth at particularly high risk include females, blacks, those of lower socio-economic status, and those who hold favorable attitudes toward illicit drugs, have detached parents, or have friends who use illicit drugs. Respondents' own use of other illicit drugs is the strongest predictor of their nonmedical use of prescription opioids. CONCLUSIONS: Nonmedical use of prescription opioids is a recurrent epidemic and valuable lessons from past epidemics of this nature can be learned if historical data are studied. Prevention campaigns should target groups at risk for substance abuse and focus on improving family bonds and peer-resistance skills.

Adolescent↗
PubMed2005

The study of direct-to-consumer advertising for prescription drugs.

OBJECTIVES: The objectives of this article are to (1) identify key methodological issues related to investigating the effects of direct-to-consumer advertising (DTCA) for prescription drugs, (2) highlight opportunities and challenges that these issues pose, and (3) provide suggestions to address these challenges and opportunities from a social and administrative pharmacy perspective. METHODS: Through a review of existing literature and consultation with research colleagues, we identified 3 broad issues regarding the study of DTCA for prescription drugs: (1) the importance of problem formulation, (2) the role of health behavior and decision-making perspectives, and (3) data collection and data analysis challenges and opportunities. Based upon our findings, we developed recommendations for future research in this area. RESULTS: Clear problem formulation will be instructive for prioritizing research needs and for determining the role that health behavior and decision-making perspectives can serve in DTCA research. In addition, it appears that cluster bias, nonlinear relationships, mediating/moderating effects, time effects, acquiescent response, and case mix are particularly salient challenges for the DTCA research domain. CONCLUSIONS: We suggest that problem formulation, selection of sound theories upon which to base research, and data collection and data analysis challenges are key methodological issues related to investigating the effects of DTCA for prescription drugs.

Advertising↗
PubMed2003

A learning prescription permits feedback on feedback.

BACKGROUND: Students consistently identified inadequate feedback as a deficiency in our third-year clerkship. METHODS: We asked students to solicit one faculty and one resident every 2 weeks for written feedback on a "feedback prescription pad." Each prescription requested four comments: two things the student did well and two things the student needs to improve. Students rated feedback using a five-point scale. A three-point categorization scheme was employed to assess the quality of feedback. RESULTS: Students' rating of feedback improved significantly compared with a previous time period (3.5 +/- 1.2 versus 2.6 +/- 1.2, P <0.01). Interrater reliability of our categorization scheme was high (kappa > or =0.75, P <0.01) and demonstrated that only 10% of comments were specific enough to qualify as effective feedback. CONCLUSIONS: Feedback prescription pads were a simple method to facilitate feedback. Although students appreciated feedback, most feedback was inadequate. Faculty development programs to enhance student feedback should be a priority of clinical medical education.

Clinical Clerkship↗
PubMed2003

Selective priming of Th1-mediated antigen-specific immune responses following oral administration of mixed prescriptions of traditional Korean medicines.

BACKGROUND: In previous studies, we showed that oral administration of traditional Korean medicines, Soamsan (SA) and Bo-yang-hwan-o-tang (BHT), modulated antigen-specific immune responses in mice. METHODS: We attempted to strengthen cell-mediated immune responses in mice using two mixed prescriptions composed mainly of components used in SA and/or BHT. The effect of oral administration of the medicines on the induction of antigen-specific immune responses was investigated using hen egg-white lysozyme (HEL) as a model antigen system. RESULTS: Following oral administration, HEL-specific cellular immune responses were enhanced in HEL low-responder mice, and the concentrations of gamma interferon (IFN-gamma), but not interleukin (IL)-4, increased significantly. In addition, the prescriptions decreased the level of HEL-specific antibodies of the immunoglobulin (Ig)G1 subtype, which is associated with helper T lymphocyte (Th2) cell stimulation. Moreover, the presence of the medicines in vitro significantly increased IFN-gamma production from mouse splenocytes, and the magnitude of the increase was closely associated with glycoprotein concentrations. CONCLUSIONS: The Korean prescriptions enhanced anti-HEL-specific cellular immune responses by selectively priming specific subtypes of the helper T cell population. Consequently, they might be useful therapy for patients who need enhanced Th1, or to suppress Th2 immune responses.

Animals↗
PubMed1997

Multicenter study on self-medication and self-prescription in six Latin American countries. Drug Utilization Research Group, Latin America.

OBJECTIVE: To evaluate the patterns of self-medication in Latin-American countries. METHODS: This cross-sectional drug utilization study took place at 242 pharmacies in 11 study areas in six countries. Unselected samples of customers were interviewed with a structured questionnaire after they had purchased a medicinal product without any medical prescription and without seeking or accepting the advice of the pharmacist or pharmacy counter assistant. RESULTS: We interviewed 8597 consumers. They had purchased 10,569 pharmaceutical products. Ten percent of the products were intended for family use, 14.1% were for children, 68.2% were for adults, and 7.9% were for elderly people. Thirty-nine percent of the products were fixed-dose combinations, and 19% contained three or more active ingredients. Analgesics (16.8%) were the leading group of drugs, followed by antibiotics (7.4%), antiinflammatory and antirheumatic products (5.9%), and vitamins (5.1%). Consumers interviewed purchased relatively high numbers of cardiovascular drugs (494, 5%) and drugs that act on the central nervous system (256, 2.4%). Only 34% of dispensed drugs had an approved over-the-counter status; less restrictive criteria suggest that 24% should have been dispensed on a medical prescription. CONCLUSIONS: The high proportion of fixed-dose combinations reflects poorly regulated pharmaceutical markets. The relatively high proportion of drugs dispensed without a medical prescription that nevertheless need medical follow-up is probably attributable to difficult access to medical care. The potential effectiveness of these treatments is therefore jeopardized by lack of medical follow-up. There is a need for implementation of a comprehensive pharmaceutical and health care policy in the participating countries.

Adolescent↗
PubMed1997

Factors influencing the prescription of hormone replacement therapy.

OBJECTIVE: To assess the effects of age, bone mineral density, risk of cardiovascular disease, and of breast cancer on the prevalence of hormone replacement therapy (HRT) prescriptions. METHODS: Seventeen charts of postmenopausal women were summarized. For each chart, we constructed 36 different cases by modifying the age (two levels), the bone mineral density (three levels), the cardiovascular risk (three levels), and the breast cancer risk (two levels). Twelve cases of these 612 files were sent to each Belgian gynecologist (n = 1010). RESULTS: Overall, HRT was prescribed in 67% of the cases. It was prescribed in 54.6% of women who had a normal bone mass, 67.9% of women with a low bone mass, and 79.0% of those with osteoporosis (P < .001). The prescription rate was higher in younger women (mean +/- standard deviation 55 +/- 4 years) than in their peers who were 10 years older (79.3% versus 55.2%; p < .001). No significant variation was observed in relation to the cardiovascular risk profile or to breast cancer risk. CONCLUSION: Osteoporosis is associated with an increased rate and older age with a decreased rate of HRT prescription, whereas no difference is observed in association with cardiovascular or breast cancer risk.

Age Factors↗
PubMed2005

[Prescription of cholinesterase inhibitors in Alzheimer's disease in France in 2000-2001: an assessment of compliance with national guidelines for diagnosis and follow-up].

INTRODUCTION: Alzheimer's disease (AD) became a treatable disease about ten years ago when cholinesterase inhibitors (CI) became available. We conducted a national population-based study in France in order to describe patients taking CI in 2001, to compare the diagnostic procedures of AD and the drug prescriptions with the French National guidelines, and to analyze the follow-up procedures of the patients. METHODS: The study was carried out in nine regions of France between December 1st 2000 and February 28th 2001 and included 3510 patients with CI treatment prescribed by the physicians affiliated with the National Social Security Health Care Fund. RESULTS: We found that the diagnostic procedures and the prescriptions were in compliance with the national guidelines with more than 90 percent of patients referred to a specialist, brain imaging in 85 percent and a MMSE scored between 10 and 26 in more than 90 percent. However, patient follow-up was in compliance with the guidelines in only 50 percent of patients. CONCLUSION: Diagnostic procedures of AD and first prescription of CI seem to be adequate in France, but patient follow-up needs to be improved.

Adult↗
PubMed1998

Racial differences in emergency department use persist despite allergist visits and prescriptions filled for antiinflammatory medications.

BACKGROUND: African-American children use the emergency department (ED) for asthma care more than their Caucasian counterparts. OBJECTIVE: We sought to compare ED utilization for asthma care by race, adjusting for prescriptions filled for antiinflammatory medications, type of index visit (specialist vs nonspecialist), and demographic variables. METHODS: An index asthma visit was identified for a cohort of managed care enrollees aged 4 to 11 years. Information on asthma encounters and drug claims data was evaluated during a prospective observation period of 12 months. RESULTS: African-American race was associated with one or more ED visits during the observation period (relative risk [RR] = 1.8, 95% CI = 1.3 to 2.5, p < 0.01). After adjusting for index visit type, prescriptions filled, and selected demographic variables, African-American race remained associated with post-index ED utilization (adjusted RR = 1.6, 95% CI = 1.0 to 2.4, p = 0.05). Additional findings included an inverse relationship between African-American race and antiinflammatory medications among children with nonspecialist index visits (RR = 0.5, 95% CI = 0.3 to 0.9, p = 0.02) and a positive relationship between African-American race and hospitalization after an ED visit for asthma care (RR = 10.2, 95% CI = 1.4 to 74.8, p < 0.01). CONCLUSION: African-American children were more likely to use ED asthma care even after adjusting for the type of index visit, prescriptions filled for antiinflammatory medications, and selected demographic variables. Racial differences in ED utilization for asthma care could be caused by a higher prevalence of uncontrolled or undertreated disease among African-American children not receiving specialty care.

Anti-Inflammatory Agents↗
PubMed2002

The effect of drug co-payment policy on the purchase of prescription drugs for children with infections in the community.

A cross-sectional study was conducted to investigate the influence of the co-payment policy in a community setting on the purchase of prescription medications for children with acute infections. Data for all purchased medications prescribed for children with an acute infectious disease were gathered from a pediatric health care center over a 6-week period. Parents of the sick children and controls were interviewed by telephone, using a short sociodemographic questionnaire, and were asked to state their reasons for not purchasing (either partially or completely) necessary medications, primarily antibiotics. Of the 779 children who received a prescription for antibiotics during the 6-week period, 162 (20.7%) failed to take the complete course of antibiotic treatment. One hundred and one parents of these children (62.3%) were interviewed, of whom 30 (29.7%) claimed that the main reason for not buying the full course of antibiotic medication was the cost. This group is characterized by low income, overcrowded housing conditions and a large quantity of prescription medications. The cost of prescribed medication under the co-payment policy is a serious barrier to the purchase of prescribed medication for children with acute infections in the primary care setting. The policy has a particularly deleterious effect in under-privileged populations and is in contradiction with the proclaimed principles of justice and equality underlying the obligatory Israeli National Israeli Health Insurance Law and similar laws in other western countries.

Acute Disease↗
PubMed2000

[Postcoital hormonal contraception: study on the attitudes and prescription of primary care physicians].

OBJECTIVE: To study the understanding, attitudes and practice of primary care doctors in the prescription of hormonal post-coitus interception, along with the social and demographic, educational, legal and ethical variables associated with this prescription. DESIGN: Cross-sectional descriptive study. SETTING: Area IV de INSALUD in Asturias. PARTICIPANTS: Family doctors, excluding locums (n = 178). MEASUREMENTS AND RESULTS: An anonymous self-administered questionnaire with 33 questions, re-sent once, between November 1999 and February 2000. The association-independence of variables was contrasted through the chi 2 test (a statistically significant association if p < 0.05). 77% responded, 51% of whom were men. Average age was 43 (SD = 6.69), with professional experience of 17 years worked (SD = 6.87). 47% were family doctors and 39% general practitioners. 85% worked in health centres; 46% in urban settings. 71% were catholics, 73% (95% CI: 66%-80%) had been asked on at least one occasion in the previous six months for the post-coitus pill (PCP), with demand greater in the urban environment (83%). 18% considered the PCP an abortion method. 88% said they would prescribe it (95% CI: 82.5%-93.5%), of which 30% (95% CI: 16%-44%) did so according to WHO recommendations. 100% of the "non-prescribers" were catholics. CONCLUSIONS: Most doctors receive requests for the PCP and prescribe it on demand, though prescription varies with age, categories and, in particular, religious belief. Only a third prescribes according to WHO recommendations.

Adult↗
PubMed1998

Changes in the demographics and prescription of peritoneal dialysis during the last decade.

Changes in the demographics and prescription of peritoneal dialysis (PD) during the past decade are reviewed using data from the United States and Canada. The number of patients in North America undergoing PD has increased markedly over the past decade, but the percentage of total chronic dialysis patients using the modality has remained relatively stable or decreased slightly during recent years. The average age of the patients undergoing PD has increased, and the percentage with diabetes has also increased. Comorbidity has otherwise remained relatively stable and tends to be significantly less than that in patients undergoing chronic hemodialysis (HD). The proportion of PD patients undergoing automated PD (APD) has increased markedly over the past decade and now includes more than one third of the PD patients in North America. The issue of adequacy of clearance achieved on PD has received a lot of attention over the past decade, and this is now being translated into changes in prescription. Patients undergoing continuous ambulatory PD (CAPD) are being prescribed larger dwell volumes, and more than one quarter use 2.5-L dwells or greater. A small number in the United States are being prescribed more than four exchanges a day, but this practice is more common in Canada. With regard to APD, the proportion of patients doing day dwells is now more than two thirds, and the average cycler dwell volumes have also increased. There are no baseline clearance data from a decade ago for comparative purposes, but it appears that clearances have increased in recent years. In general, more than 70% of the patients are achieving recommended clearance targets at the initiation of PD but, among prevalent US patients, the percentage achieving targets is in the range of 40% to 45%, reflecting a loss of residual renal function. In Canada, 60% to 70% of prevalent patients are achieving these targets. PD is a rapidly changing therapy at present. There have been dramatic and impressive improvements in prescription practices, but they need to change further if a higher proportion of patients is to achieve recommended clearance targets.

Adult↗
PubMed2001

Individualization of dose prescription based on normal-tissue dose-volume and radiosensitivity data.

PURPOSE: The aim of this paper is to illustrate the potential gain in tumor control probability (TCP) of prostate cancer patients by individualizing the prescription dose according to both normal-tissue (N-T) dose-volume and radiosensitivity data. METHODS AND MATERIALS: Two exercises have been carried out. Firstly, patients' dose prescriptions were individualised on the basis of N-T dose-volume histograms (DVHs) alone and secondly modeling potential differences in N-T sensitivity as well. In both cases, the change in tumor control that may be achieved by individualizing patients' dose was estimated assuming that after the dose adjustments, every patient had (1) the same value of normal tissue complication probability (NTCP) (5%) and (2) NTCP equal to the average NTCP before individualization (i.e., without increasing the average NTCP). The Lyman-Kutcher-Burman NTCP model was used to predict the N-T response curves with two different sets of parameters. The first exercise, based only on individual NT DVHs (i.e., assuming all patient equally radiosensitive), was over a real population of 50 prostate cancer patients. The second exercise modeled a 10,000-prostate-cancer patient population with varying NT dose-volume distributions and radiosensitivity (through allowing TD(50) to vary). RESULTS: A gain of more than 9% in TCP was predicted when doses were individualized based only on DVHs so that every patient had 5% NTCP after dose adjustments. By adding the estimate of radiosensitivity, the gain increased to more than 15%. When the individualisation was performed without increasing the mean NTCP, then the potential gain in TCP was almost 5% (for adjustment based on DVH distribution solely) increasing to 7% with the additional consideration of radiosensitivity. CONCLUSIONS: There is a potential gain (increase in local tumor control) from dose individualisation strategies based on both N-T dose-volume data and radiosensitivity (assuming that this is available). Dose prescription individualization based only on dose-volume data can be exploited provided that reliable N-T response models are available. There will be additional gains if some estimate of N-T radiosensitivity is available to allow further patient stratification, identification of patients with high radiosensitivity being particularly important.

Algorithms↗
PubMed2004

[Prescription of high dose buprenorphine by general practitioners].

BACKGROUND: Since 1996, prescribing buprenorphine in high dosage as a drug maintenance treatment has been allowing French general practitioners to undertake drug addicts with a pharmacological support. In France, buprenorphine prescriptions seem to spread over general practitioners (buprenorphine was given to 74,300 patients in 2001). This paper assesses the different factors associated with buprenorphine prescription by general practitioners and with the different degrees of general practitioners' commitment in actually caring drug addicts with the help of buprenorphine. METHODS: Two representative samples of private general practitioners, either prescribing buprenorphine (345 over a population of 876) or not prescribing (355 over a population of 1380) have been questioned through a phone interview in the department of South-Eastern France in November and December 2002. Samples have been constituted with the help of a random stratified survey according to sex, age and volume of services (acceptance rate: 65.5%). Survey data have been completed with general practitioners' activity data from Health Insurance and local socioeconomic data from Insee. RESULTS: 37.5% of general practitioners have at least once prescribed buprenorphine during the considered period, but only 26% of the prescribers treated 75% of patients. Prescribers are most often men, younger than 49 years, working in the fixed fees sector and having group practice. They are also most often members of a health care network, trained for drug maintenance treatments and, from an individual point of view, have relatives suffering cancer, or having HIV, or hepatitis C, or who are drug addicts. Low socioeconomic status of the area where GPs exert seems to be particularly associated with general practitioners' prescription of buprenorphine. CONCLUSION: Data handled in this paper show that supply of substitutive treatments is concentrated among a reduced number of general practitioners and in particularly deprived geographic areas. Workload in deprived areas combined to great professional commitment in maintenance treatment reveals unexpected and unwanted specialisation behaviours by general practitioners, as well as more isolated behaviours by general practitioners who do not ask for particular training program or help by colleagues. These results question the consistency of the general framework of support to general practitioners proposed by health authorities with general practitioners actual practice and needs.

Analgesics, Opioid↗
PubMed2004

[Control scale of antibiotic prescriptions in intensive care].

THE PROBLEM TO BE SOLVED: The improvement in the prescription of antibiotics (PA) is currently one of the stages necessary for the management of bacterial resistances. Patients admitted to intensive care, because of an acute affection or fragile territory, are frequently administered an antibiotic. The inappropriate nature of the PA is noted in 30 to 50% of cases. The inadequacy of the initial antibiotic therapy leads to an excessive increase in mortality and morbidity. THE DEVELOPMENT OF A CONTROL TOOL: In order to improve our habits and help the prescribers, a panel of experts discussed the subject of the prescription of antibiotics during the 3rd day of the Outcomerea Group. At the end of this meeting, practical guidelines together with a scale for the control of the prescription of antibiotics had been established. COMMENTS: We targeted our discussion on the importance of empirical treatment and the need to document the infectious episode. Moreover, we discussed the choice of the antibiotic molecule and the crucial need to reassess the treatment set-up. We also approach the place of combinations of antibiotics and their indications in our units as well as the optimal duration of the treatments.

Anti-Bacterial Agents↗
PubMed2002

Attitudinal factors among adult prescription recipients associated with choice of where to be vaccinated.

The objective of this article was to evaluate adult prescription recipients' choices among vaccine providers. The study setting was a cluster sample from 24 community pharmacies based on prescription records that suggested need for pneumococcal and influenza vaccines. Vaccination status, choice of vaccine provider, and opinions regarding vaccine providers were retrospectively surveyed by mail in spring 1999. Overall, 52% of survey recipients responded; 89% of respondents reported returning to the same type of vaccine provider in consecutive years. Two key factors affected choice of provider: convenience and provider experience. Convenience was a stronger factor for people younger than 65 taking chronic medications and those not vaccinated in the previous year. Most adult recipients of influenza vaccine returned to sites where they were vaccinated the previous year. Convenience was a major factor in vaccination decisions of adult prescription recipients.

Adult↗
PubMed1997

Relation of prescription nonsteroidal antiinflammatory drug use to cognitive function among community-dwelling elderly.

PURPOSE: To evaluate the relationship of nonsteroidal antiinflammatory drug (NSAID) use to level of cognitive function in community-dwelling elderly persons. METHODS: The prospective cohort study included 2765 nonproxy subjects from the Duke University Established Populations for Epidemiologic Studies of the Elderly who were cognitively intact at baseline (1986-1987) and alive at follow-up three year later. Cognitive function was assessed by the Short Portable Mental Status Questionnaire (i.e., intact vs. impaired and change in score) and by the individual domains of the Orientation-Memory-Concentration Test (i.e., number of errors). NSAID use, determined from in-home interviews, was coded for chronicity, dose, frequency of use, and prescription status. RESULTS: After controlling for demographic factors as well as health status and behavior, continuous, regularly-scheduled, prescription use of NSAID was associated with preservation of one aspect of cognitive functioning: concentration (beta coefficient, 0.29; 95% confidence interval [CI] -0.54 to -0.04, indicating fewer errors). However, no consistent dose-response relationship was found. Current and prior NSAID use was unrelated to level of cognitive functioning across all five measures; among current users, those taking moderate or high doses (beta coefficient, 0.41; 95% CI, 0.08 to 0.74) made more errors on the memory test compared with those taking low doses (beta coefficient 0.03; 95% CI, -.85 to 0.91). CONCLUSIONS: These results suggest no substantial or consistent protective effect of prescription NSAID use on cognitive function in community-dwelling elderly. However, recent use at higher doses may be associated with memory deterioration in this population.

Aged↗
PubMed2002

High-risk teen compliance with prescription contraception: an analysis of Ohio Medicaid claims.

STUDY OBJECTIVE: This study examines utilization of and compliance with prescription contraception by adolescents. DESIGN: Retrospective cohort analysis of billing and pharmacy claims. SETTING: Ohio Medicaid fee-for-service enrollees. PARTICIPANTS: Claims data of 12- to 19-year-olds identified at high risk for pregnancy by sexually related service billing or procedure code. MAIN OUTCOME MEASURE: Prescription contraception use and compliance patterns were examined over a 12-month study period. RESULTS: During a 6-month enrollment period, 3338 females were identified at risk for pregnancy. Over one-fourth (920) became pregnant. Across the 12-month follow-up, 40% (1328) used no prescription contraception and 33% (1090) used some prescribed contraceptive. Most teens used injectable medroxyprogesterone (517) or oral contraceptive pills (492). About 20% of those using any type of prescribed contraceptive were compliant for the full year; less than 30% used a method for 3 months or less. Whites were more compliant with contraception than nonwhites. Younger age and concurrent mental health condition were also predictors of noncompliance. CONCLUSIONS: Teens at risk for pregnancy demonstrated poor compliance with prescribed contraceptives. Billing/pharmacy claims analysis is a useful tool for identifying teens at risk for pregnancy in order to target and evaluate interventions or to benchmark care provided to adolescents.

Adolescent↗