Concomitant antipsychotic prescribing in US outpatient settings.

BACKGROUND: Clinicians use concomitant antipsychotic therapy for management of psychotic disorders despite a paucity of evidence for this practice. OBJECTIVE: To examine national patterns and determinants of concomitant antipsychotic therapy. METHODS: Concomitant antipsychotic therapy was defined as simultaneous use of 2 or more antipsychotic agents. Prescription data from the 2003-2004 National Ambulatory Medical Care Survey and the outpatient department portion of the 2003-2004 National Hospital Ambulatory Medical Care Survey were used to characterize the prescribing of concomitant antipsychotic therapy and antipsychotic monotherapy (defined as use of a typical or atypical agent). Multiple logistic regression was applied to antipsychotic visits to examine the determinants of concomitant antipsychotic therapy based on patient and provider characteristics. RESULTS: Overall, concomitant antipsychotic therapy was documented in 9% of the visits involving antipsychotic agents, and monotherapy in 91% of the visits. The use of atypical agents, namely risperidone, olanzapine, and quetiapine, was common in both forms of therapy. Concomitant therapy was frequently used for psychoses and bipolar disorder. Logistic regression revealed that the odds of receiving concomitant antipsychotic therapy were higher for patients younger than 65 years, with greatest odds (odds ratio=6.52) for patients 40 to 64 years old. Having a diagnosis of psychosis quadrupled (odds ratio=4.33) the odds of receiving concomitant antipsychotic therapy. Physicians in metropolitan areas were more likely (odds ratio=2.17) to use concomitant antipsychotic therapy than physicians in non-metropolitan areas. CONCLUSIONS: Concomitant antipsychotic therapy continues to be prevalent and extensive in outpatient settings. With the use of concomitant antipsychotic therapy as a quality of care measure, there is a need to optimize prescribing of these potent combinations.

Hospitalization risk associated with typical and atypical antipsychotic use in community-dwelling elderly patients.

BACKGROUND: Due to age-related changes in drug disposition and response, elderly patients are more susceptible to the adverse effects of antipsychotic medications than younger adults. However, few studies have examined the impact of typical and atypical antipsychotic use on all-cause hospitalization in the elderly population. OBJECTIVE: This study compared the short-term effects of incident use of typical and atypical antipsychotic agents on the risk for hospitalization in a community-dwelling elderly population. METHODS: This retrospective data analysis involved a longitudinal cohort of typical and atypical antipsychotic users and was based on data from the 1996-2004 Medical Expenditure Panel Survey. Typical antipsychotic agents included chlorpromazine, fluphenazine, haloperidol, levomepromazine, loxapine, mesoridazine, molindone, perphenazine, promazine, thioridazine, thiothixene, and trifluoperazine. Atypical antipsychotic agents included aripiprazole, clozapine, olanzapine, quetiapine, risperidone, and ziprasidone. Incident cases of antipsychotic use in community-dwelling elderly (aged > or =60 years) persons were selected for the assessment of risk for all-cause hospitalization within 60 days of exposure to antipsychotics. Bivariate analyses were used to compare baseline characteristics; multivariate logistic regression was used to compare hospitalization risk among users of typicals and atypicals after controlling for age, sex, race, income, insurance coverage, perceived general health, perceived mental health, and other concurrent psychotropic use. RESULTS: The analytical sample consisted of 124 community-dwelling elderly patients (atypicals, 75 patients; typicals, 49). A majority of the elderly study sample were women (63%), white (79%), and of middle/high income (57%). The mean (SD) age of the study sample was 74.37 (8.65) years. There were no significant differences in baseline characteristics between typical and atypical users, with the exception of perceived mental health status. After controlling for other factors, the risk for hospitalization was nearly 4-fold higher with typical antipsychotic use than atypical use (odds ratio, 3.81; 95% CI, 1.12-12.99). CONCLUSION: In this population of community-dwelling elderly, use of typical agents was associated with an increased risk for hospitalization compared with atypical agents.

Determinants of atypical antipsychotic use among antipsychotic users in community-dwelling elderly, 1996-2004.

OBJECTIVES: This study examined the determinants of atypical antipsychotic use among antipsychotic users in community-dwelling elderly in the United States. METHODS: The study involved analysis of household and prescription files of the Medical Expenditure Panel Survey (MEPS) data from 1996 to 2004. The analysis focused on the use of six atypical antipsychotic agents namely, clozapine, olanzapine, risperidone, quetiapine, ziprasidone, and aripiprazole among the elderly of 60 years or older. Multiple logistic regression analysis within the conceptual framework of Andersen's Behavioral Model was used to examine the determinants of atypical antipsychotic use among antipsychotic users in community-dwelling elderly. RESULTS: An average of 0.62 million elderly received antipsychotic agents annually during the study period. A majority of the elderly using antipsychotic agents were female (70%), white (86%), non-Hispanic (95%), and living in metropolitan statistical areas (79%). Frequently reported diagnoses among the elderly taking antipsychotic agents were dementia (26.12%), anxiety (20.42%), and schizophrenia (6.62%). Of the elderly receiving antipsychotic agents, 50.39% received atypical agents and 51.88% received typical agents during the study period. The most frequently used atypical agents were risperidone, olanzapine, and quetiapine. Multivariate logistic regression analysis revealed that need (perceived mental health, p < 0.01) and enabling (time, p < 0.01) factors were significantly associated with atypical antipsychotic use after controlling for predisposing factors. The study found that elderly patients with relatively poor perception of mental health (need) and utilization of antipsychotic agents after 1998 (enabling) were more likely to involve the use of atypical agents. LIMITATIONS: This study was limited to the use of antipsychotic agents in community settings and cannot be extrapolated to other settings. Correlates examined in this study were limited to variables available from the data source and those used by previous researchers. CONCLUSIONS: Need and enabling factors play a vital role in the use of atypical agents in the elderly. The findings have important implications in understanding the use and outcomes of atypical agents in the elderly. Future pharmacoepidemiological research can use these variables to control for confounding and selection bias when evaluating health care outcomes in observational studies.

Online pharmacies: safety and regulatory considerations.

Sales of consumer products over the Internet have grown rapidly, including sales of pharmaceutical products. Online pharmacies mimic mail order pharmacies. To operate legally online, pharmacies must be licensed in every state in which sales occur. Although online pharmacies provide benefits to consumers, when compared with traditional pharmacies patients' safety may be compromised. Purchasing prescription drugs online may pose a risk to consumers because they cannot tell whether the site is offering drugs of the same quality offered by a retail pharmacy. There is also a possibility that prescription drugs purchased online may be counterfeit, illegal, or unapproved. A U.S. General Accounting Office study conducted in June 2004 showed that most counterfeit and unapproved drugs sold online are from non-U.S. pharmacies. The Food and Drug Administration and other government agencies have worked to enforce laws on drug sales over the Internet. The biggest challenge in regulating non-U.S. pharmacies is due to their off-shore location. Unfortunately, given the widespread anonymous and ever-changing nature of the Internet, it is very difficult to close down illegal websites.

Healthcare outcomes associated with beers' criteria: a systematic review.

OBJECTIVE: To examine healthcare outcomes associated with Beers' criteria of inappropriate medication use based on a literature review. DATA SOURCES: A search of MEDLINE, International Pharmaceutical Abstracts, and Cumulative Index to Nursing and Allied Health Literature was conducted to identify articles published from October 1991 to October 2006. The following key words were used: Beers, inappropriate, medication, drug, use, prescribing, and elderly. A manual search was also conducted using the references listed in the articles identified through the database search. STUDY SELECTION AND DATA EXTRACTION: Studies that examined the impact or outcomes of Beers' criteria of inappropriate medication use (1991, 1997, and 2003 critera) were selected. Each article was examined for study setting, data source, study sample, study design, criteria, analysis and covariates, type of healthcare outcome, and study findings. Of 235 articles retrieved, 18 presented studies that examined healthcare outcomes associated with inappropriate medication use based on Beers' criteria. Specifically, setting-specific evidence as well as overall evidence was examined from the selected studies. The review considered evidence of association if more than 50% of the findings were statistically significant. DATA SYNTHESIS: Most of the 18 studies evaluated were retrospective cohort studies involving patients 65 years of age or older from diverse healthcare settings. In community settings, there was no evidence of association with respect to mortality and other healthcare use, and evidence regarding quality of life and costs was inconclusive. However, inappropriate medication use was associated with hospitalization measures in community elderly. In nursing homes, there was no evidence of association with mortality and the association with hospitalization measures was inconclusive. In hospitals, there was inconclusive evidence to make any generalizations. Across healthcare settings, inappropriate medication use was associated with adverse drug reactions and costs but not with other outcome measures. CONCLUSIONS: There is evidence that Beers' criteria of inappropriate medication use is associated with adverse healthcare impact in the community-dwelling elderly. With increasing use of Beers' criteria as quality-of-care measures, there is a need to strengthen the predictive validity of these criteria in all healthcare settings.