Insights into patient characteristics and documentation of the use of sedative-hypnotic/anxiolytics in primary care: a retrospective chart review study.

BACKGROUND: Despite the known safety risks of long-term use of sedative-hypnotic/anxiolytic medications, there has been limited guidance for the safe and effective use of their chronic use in a primary care clinic setting. Understanding the characteristics of patients who receive sedative-hypnotic/anxiolytic medication and the clinical documentation process in primary care is the first step towards understanding the nature of the problem and will help inform future strategies for clinical research and practice. OBJECTIVES: Characterize patients who received a sedative-hypnotic/anxiolytic prescription in primary care, and (2) gain an understanding of the clinical documentation of sedative-hypnotic/anxiolytic indication and monitoring in electronic medical records (EMR). METHODS: A random selection of patients who received a prescription for a benzodiazepine or Z-drug hypnotic between January 2014 and August 2016 from four primary care clinics in Winnipeg were included. Data was collected retrospectively using the EMR (Accuro®). Patient variables recorded included sex, age, comorbidities, medications, smoking status, and alcohol status. Treatment variables included drug type, indication, pattern of use, dose, adverse events, psychosocial intervention, tapering attempts, social support, life stressor, and monitoring parameters for sedative-hypnotic use. Demographic and clinical characteristics were described using descriptive statistics. RESULTS: Records from a sample of 200 primary care patients prescribed sedative-hypnotic/anxiolytics were analyzed (mean age 55.8 years old, 61.5% ≥ 65 years old, 61.0% female). Long-term chronic use (≥ 1 year) of a sedative-hypnotic/anxiolytic agent was observed in 29.5% of the sample. Zopiclone (30.7%) and lorazepam (28.7%) were the most common agents prescribed. Only 9.5% of patients had documentation of a past tapering attempt of their sedative-hypnotic/anxiolytic. The most common indications for sedative-hypnotic/anxiolytic use recorded were anxiety (33.0%) and sleep (18.0%), but indication was undetermined for 57.0% of patients. Depression (33.5%) and falls (18.5%) were reported by patients after the initiation of these agents. CONCLUSIONS: A higher proportion of females and users 65 years and older received a prescription for a sedative-hypnotic/anxiolytic, consistent with previous studies on sedative-hypnotic use. We found inconsistencies in the documentation surrounding sedative-hypnotic/anxiolytic use. The indication for their use was unclear in a large number of patients. These findings will help us understand the state of the problem in primary care and inform future strategies for clinical research.

Statin-prescribing trends for primary and secondary prevention of cardiovascular disease.

OBJECTIVE: To determine the proportion of patients receiving statins for primary or secondary prevention of cardiovascular disease (CVD), as well as to describe lipid-screening trends. DESIGN: Retrospective chart review using the Manitoba Primary Care Research Network repository. SETTING: Manitoba. PARTICIPANTS: A total of 149 262 patients. MAIN OUTCOME MEASURES: Proportion of patients who were taking statins for primary or secondary prevention of cardiovascular disease (CVD), who did not have evidence of CVD recorded in their charts, and who underwent lipid screening; distribution of statins among age groups; and the proportion of patients eligible for lipid screening when the age cutoffs of the 2012 and 2016 Canadian Cardiovascular Society guidelines were applied. RESULTS: Of the 149 262 patients, 139 025 (93%) did not have CVD recorded in their electronic medical records and made up the primary prevention group; of these 139 025 patients, 5955 (4%) were taking statins. Also in the primary prevention group, 14 814 (11%) patients were 75 years of age and older; of these patients, 1374 (9%) were taking statins. A total of 10 237 of the 149 262 (7%) patients had CVD recorded in their charts (secondary prevention group); 3013 (29%) of these patients were taking statins. When the 2016 Canadian Cardiovascular Society guidelines age cutoffs were applied, 56% of patients (83 119 of 149 262) were eligible for lipid screening, and 31% (26 024 of 83 119) of them had evidence of screening in the past 5 years. Of the total population of those aged 75 and older, 28% (5597 of 20 188) had undergone lipid screening. Of the total population taking statins, 28% (2481 of 8968) had undergone lipid testing while taking statins. CONCLUSION: In Manitoba, less than 5% of the primary prevention population and less than 30% of the secondary prevention population had received repeat statin prescriptions from their primary care providers. This represents a possible practice gap that warrants future research, as statins offer considerable morbidity and mortality benefits in these patients.

Explaining variation in cancer survival between 11 jurisdictions in the International Cancer Benchmarking Partnership: a primary care vignette survey.

OBJECTIVES: The International Cancer Benchmarking Partnership (ICBP) is a collaboration between 6 countries and 12 jurisdictions with similar primary care-led health services. This study investigates primary care physician (PCP) behaviour and systems that may contribute to the timeliness of investigating for cancer and subsequently, international survival differences. DESIGN: A validated survey administered to PCPs via the internet set out in two parts: direct questions on primary care structure and practice relating to cancer diagnosis, and clinical vignettes, assessing management of scenarios relating to the diagnosis of lung, colorectal or ovarian cancer. PARTICIPANTS: 2795 PCPs in 11 jurisdictions: New South Wales and Victoria (Australia), British Columbia, Manitoba, Ontario (Canada), England, Northern Ireland, Wales (UK), Denmark, Norway and Sweden. PRIMARY AND SECONDARY OUTCOME MEASURES: Analysis compared the cumulative proportion of PCPs in each jurisdiction opting to investigate or refer at each phase for each vignette with 1-year survival, and conditional 5-year survival rates for the relevant cancer and jurisdiction. Logistic regression was used to explore whether PCP characteristics or system differences in each jurisdiction affected the readiness to investigate. RESULTS: 4 of 5 vignettes showed a statistically significant correlation (p<0.05 or better) between readiness to investigate or refer to secondary care at the first phase of each vignette and cancer survival rates for that jurisdiction. No consistent associations were found between readiness to investigate and selected PCP demographics, practice or health system variables. CONCLUSIONS: We demonstrate a correlation between the readiness of PCPs to investigate symptoms indicative of cancer and cancer survival rates, one of the first possible explanations for the variation in cancer survival between ICBP countries. No specific health system features consistently explained these findings. Some jurisdictions may consider lowering thresholds for PCPs to investigate for cancer-either directly, or by specialist referral, to improve outcomes.

Use of fecal occult blood test in hospitalized patients: survey of physicians practicing in a large central Canadian health region and Canadian gastroenterologists.

BACKGROUND: Although the fecal occult blood test (FOBT) was developed for colorectal cancer screening in the outpatient setting, it continues to be used among hospitalized patients. No previous study has evaluated the knowledge, beliefs and attitudes of practicing physicians on the use of FOBT among hospitalized patients and compared practices among physicians with different medical specialty training. OBJECTIVE: To survey physicians in the Winnipeg Regional Health Authority (WRHA) and Canadian gastroenterologists (GIs) on the use of FOBT in hospitals. METHODS: A survey was distributed by e-mail to internists (n=198), emergency medicine (EM) physicians (n=118), general surgeons (n=47) and family medicine (FM) physicians with admitting privileges (n=29) in the WRHA. Canadian GIs were surveyed through the membership database of the Canadian Association of Gastroenterology (CAG) (n=449). The survey included items regarding demographics of the respondents and their current use of FOBT in hospitals. RESULTS: Response rates ranged from 18% among CAG members to 69% among FM physicians in the WRHA. General internal medicine, general surgeon and GI respondents were less likely to order a FOBT and less likely to believe that an FOBT was useful in assessing emergency room or hospitalized patients when compared with FM and EM respondents (P<0.001). The most common indications for ordering a FOBT were black stools and anemia with and without iron deficiency. Two-thirds of EM physicians preferred point-of-care testing rather than laboratory reporting of FOBT. CONCLUSIONS: The present survey suggests that FOBTs are commonly used in hospitals by EM and FM physicians for indications such as anemia and black stools.

Are medication restrictions before FOBT necessary?: practical advice based on a systematic review of the literature.

OBJECTIVE: To determine whether medication interventions enhance the sensitivity and specificity of guaiac-based fecal occult blood testing (FOBT) when screening for colorectal cancer (CRC). DATA SOURCES: We searched PubMed-MEDLINE, CINAHL, and the Cochrane databases using the MeSH headings occult blood, feces/analysis, and guaiac/analysis, linking them to variations of anticoagulants, heparin, warfarin, iron, aspirin, nonsteroidal anti-inflammatory drugs (NSAIDs), clopidogrel, cyclooxygenase-2 inhibitors, and ascorbic acid (vitamin C). Study selections were limited to English studies involving humans. STUDY SELECTION: All resulting titles and abstracts were reviewed for studies that included manipulation of medications associated with guaiac-based FOBT. If the study's relevance was unclear from the abstract, the full article was reviewed. The search resulted in 31 pertinent studies. SYNTHESIS: No studies addressed the effects of medication interventions on the sensitivity or specificity of FOBT screening. Randomized controlled trials, however, showed no increase in the rate of positive results among those taking NSAIDs. The literature is mixed regarding the effect of NSAIDs on the positive predictive value of a positive FOBT result, although no change in positive predictive value has been shown for warfarin. Iron will not affect FOBT results in vivo. Ascorbic acid might inhibit positive FOBT results both in vitro and in vivo, but it has not been studied in screening populations. CONCLUSION: Studies evaluating the effects of medication intervention on FOBT screening for CRC are limited by their lower quality and because they do not address sensitivity and specificity. Available evidence, however, does not suggest a benefit from withholding NSAIDs, anticoagulant medications, or iron during the screening period. These recommendations should be abandoned in order to maximize adherence to screening. Positive FOBT results obtained among patients taking these medications deserve full evaluation for CRC. Until further studies clarify the effect of ascorbic acid on FOBT screening, withholding this medication before testing seems prudent.

Dietary interventions for fecal occult blood test screening: systematic review of the literature.

OBJECTIVE: To determine whether dietary restrictions enhance the specificity of guaiac-based fecal occult blood tests (FOBTs) when screening for colorectal cancer. DATA SOURCES: PubMed-MEDLINE, the Cumulative Index to Nursing and Allied Health Literature, and Cochrane databases were searched. STUDY SELECTION: English-language case series, cohort studies, randomized controlled trials (RCTs), and meta-analyses were selected. Studies that did not include dietary manipulation or the use of guaiac-based FOBTs available in North America were excluded. SYNTHESIS: Ten case series, 5 cohort studies, 4 RCTs, and 1 meta-analysis were critically appraised. All studies used Hemoccult, Hemoccult II, or Hemoccult SENSA tests. Data from case series involving challenge diets showed no increase in positive FOBT results from high-peroxidase vegetables, but results varied with red-meat challenges depending on the amount of meat consumed and the test used. Case series, cohort studies, and RCTs comparing FOBT results during restricted versus unrestricted diets consistently showed no differences in positive FOBT results. CONCLUSION: Most of the evidence evaluating the effect of dietary restrictions on FOBT results is dated and of suboptimal quality. However, 4 RCTs and a meta-analysis of these data do not support dietary restrictions when screening for colorectal cancer. Because patient adherence can be an issue with FOBTs, and dietary restrictions can affect adherence in some populations, it is reasonable to abandon these recommendations without fear of substantially affecting specificity.

Prevention of neonatal group B streptococcal infection: approaches of physicians in Winnipeg, Man.

OBJECTIVE: To determine how family physicians in Winnipeg, Man, approach prevention of neonatal group B streptococcal (GBS) infection, what influences their decisions, and whether their decisions differ from those of local obstetricians. DESIGN: Population-based survey. SETTING: Family physicians' and obstetricians' practices in Winnipeg. PARTICIPANTS: Eighty-five physicians and residents with hospital labour floor privileges. MAIN OUTCOME MEASURES: Individual approaches to prevention of neonatal GBS infection, factors influencing choice of approach, and perceptions of neonatal GBS disease and universal prenatal GBS screening. RESULTS: About 66% of family physicians and their residents followed the Society of Obstetricians and Gynaecologists of Canada's (SOGC) guidelines for universal GBS screening and intrapartum antibiotic prophylaxis of all GBS carriers. This was significantly fewer than the 87% of obstetricians who followed these guidelines (P = .026). Obstetricians were more likely than family physicians to cite the literature as influencing their approach to neonatal GBS prevention (P < .001). Family physicians were more likely to cite the influence of peers and colleagues (P = .04). The incidence of neonatal GBS and its associated mortality were overestimated by 61% and 55% of obstetricians, and 66% and 57% of family physicians, respectively. Despite concerns about the risks and costs of universal GBS screening and intrapartum antibiotic prophylaxis, 92% of obstetricians and 79% of family physicians thought that the benefits of universal screening outweighed the concerns. About 24% of obstetricians and 30% of family physicians were theoretically willing to expose more than 10,000 women to intrapartum prophylactic antibiotics to prevent a single neonatal GBS-related death. CONCLUSION: Family physicians were less likely than obstetricians to follow current SOGC guidelines for prevention of neonatal GBS disease. This could reflect a different perspective on patient care. Family physicians want patients to be involved in screening decisions based on full disclosure of potential harm and benefit.

Epidemiology of early-onset neonatal group B streptococcal infection: implications for screening.

OBJECTIVE: To determine the difference in outcomes between universal screening and risk-based assessment for prenatal group B streptococcus (GBS) infection based on the epidemiology of early-onset GBS infection in Winnipeg, Man, and to examine its implications for prenatal GBS screening. DESIGN: Retrospective random chart audit of 330 women receiving intrapartum hospital care and retrospective chart audit of all infants with early-onset neonatal GBS disease over 2 years. SETTING: Each of the 3 hospitals in Winnipeg, Man, offering intrapartum services. MAIN OUTCOME MEASURES: Maternal charts were audited for history of prenatal GBS screening, GBS status, clinical risk factors for neonatal GBS transmission, and use of intrapartum antibiotics to prevent neonatal GBS infection. Neonatal GBS records were audited for maternal clinical risk factors for GBS transmission, history of maternal GBS screening and GBS status, use of maternal intrapartum antibiotic prophylaxis, and neonatal outcome. RESULTS: Screening revealed a 26% GBS carrier rate in our population. Among these carriers, 70% (or 18% of the population) had no other clinical risk factors for neonatal GBS transmission. The transmission rate for untreated GBS-positive women was 1.74 per 1000 women. The differences in outcomes between universal and risk-based screening were small in our population. A total of 3449 women would require universal screening to prevent a single case of early-onset neonatal GBS disease that would occur if a risk-based approach were used (3 cases per year). This number increases to 68,966 to prevent a single GBS-related death (1 case in 7 years). An additional 679 women would receive intrapartum prophylactic antibiotics per year with universal screening than would have received antibiotics with a risk-based approach. CONCLUSION: The differences in neonatal GBS transmission rates resulting from universal versus risk-based screening in Winnipeg require universal screening of many women for results to become apparent. Universal screening and antibiotic prophylaxis of all GBS carriers result in increased antibiotic exposure in our population, which might carry its own risks. Therefore, patients should be involved in decisions on whether to be screened based on identification of risks and benefits.