Assessing the Appropriateness of Antimicrobial Prescribing in the Community Setting: A Scoping Review.

Background: This scoping review examined the concept and scope of appropriateness of antimicrobial prescribing in the community setting and how it has been measured. Methods: Utilizing the Joanna Briggs Institute's methodology, we appraised peer-reviewed articles and unpublished studies, focusing on the US, UK, Canada, and Australia, with no limit to date. Results: Four basic components of antimicrobial prescribing to be evaluated during assessment of antimicrobial appropriateness in the community setting were identified: diagnosis for infection or indication for antimicrobial therapy, choice of antimicrobial therapy, dosing, and duration of therapy. The benchmark for definition of appropriateness is crucial in assessing antimicrobial prescribing appropriateness. The use of recommended guidelines as a benchmark is the standard for appropriate antimicrobial therapy, and when necessary, susceptibility testing should be explored. Conclusions: Studies evaluating the appropriateness of antimicrobial prescribing should assess these components of antimicrobial prescribing, and this should be clearly stated in the aim and objectives of the study.

Assessment of inhaler technique among fourth-year pharmacy students: Implications for the use of entrustable professional activities.

INTRODUCTION: It is unknown when and how often competency assessments should occur in pharmacy education. Using inhaler technique as an example competency, the study objectives were to measure the proportion of near-graduation students demonstrating correct technique approximately one year after initial training and to measure reliability between assessors. METHODS: A sample of 45 near-graduation pharmacy students with prior education on correct inhaler technique participated in this direct observation study at the University of Otago. Five trained assessors simultaneously rated each participant's inhaler technique demonstration using a checklist. RESULTS: Of 37 participants demonstrating a pressurized metered dose inhaler, 21.62% demonstrated correct technique. No participants among eight volunteers demonstrated proper use of a dry powder inhaler. On average, two steps were performed correctly for each inhaler type. Steps with the highest error rate were "hold the inhaler upright and shake well," "breath out gently, away from the inhaler," and "keep breathing in slowly and deeply". The intraclass correlation coefficient for any inhaler type was excellent (0.91), suggesting assessors had strong reliability. CONCLUSIONS: Students did not retain ability to correctly demonstrate inhaler technique one year after initial instruction. This finding supports the notion that demonstrable tasks may need to be frequently assessed to ensure the task is mastered and becomes a routine part of a student's practice. It also suggests that assessment of milestones and/or entrustable professional activities may need to occur at different time points throughout a program, rather than allowing for "signing off" prematurely.

Tapering Biologic Therapy for Rheumatoid Arthritis: A Qualitative Study of Patient Perspectives.

BACKGROUND AND OBJECTIVE: Biologic therapies are cost effective for active rheumatoid arthritis but have adverse effects and are costly. Tapering of biologics is emerging as an important consideration when sustained remission is achieved. Recent trials have highlighted the clinical feasibility of tapering, but there is little evidence on how proposed tapering would be received by patients. The aim of this study was to explore factors influencing hypothetical decisions of patients with rheumatoid arthritis on tapering their biologics and their perspectives on remission and flare when considering the possibility of tapering. METHODS: Patients with rheumatoid arthritis with diverse experiences of biologics with different modes of administration were purposively sampled to participate in one of six focus groups (n = 43) or an individual interview (n = 2). Transcripts were analyzed using inductive thematic analysis. RESULTS: Five overarching themes on what influences a participant's decision to taper their biologic were identified. First, participants were fearful of uncertain outcomes of tapering, especially flare and joint damage. Second, participants prioritized quality of life from continuing biologics over the risk of adverse effects. Third, tapering biologics was seen as providing relief from the inconvenience of taking biologics regularly. Fourth, participants wanted assurance of prompt access to healthcare if their rheumatoid arthritis were to flare when tapering. Fifth, preferences for involvement in decision making varied, but fulfilling information needs was desired to aid a patient's preferred role in decision making on tapering. CONCLUSIONS: This study provides novel insight into the perspectives of patients with rheumatoid arthritis on tapering biologics when sustained remission is achieved at a crucial juncture in global affordability for healthcare systems. These patient perspectives can inform the planning of decision aids and clinical trials of decision-making processes when tapering is proposed.

An overview of pharmacoepidemiology in New Zealand: medical databases, registries and research achievements.

Pharmacoepidemiology is an eclectic blend of epidemiology, clinical pharmacology and biostatistics. In New Zealand there have been recent advances in pharmacoepidemiology to examine drug utilisation, monitor adverse drug events and complement pharmacovigilance. This paper attempts to describe the past, present and future of pharmacoepidemiology, particularly in the area of translational research with a particular focus on medicine use and safety. New Zealand is well-positioned globally to make significant contributions to the knowledge base of drug safety in real-world settings.

Glucose monitoring in new users of second-generation antipsychotics in older people.

OBJECTIVE: Treatment guidelines published world-wide have highlighted concerns of increased metabolic risks associated with second-generation antipsychotics (SGAs). The aim of the study was to evaluate blood glucose monitoring rates for SGA new users in older people aged 65 years and above during the study period 2006-2012, and investigate the pre-post 2007 Best Practice Advocacy Centre's (bpacnz) glucose monitoring recommendation in New Zealand. METHODS: The study was a population-based retrospective cohort of SGA new users (365days without pre-exposure to antipsychotics). Pharmaceutical collections data were extracted and used to identify older people dispensed SGAs and linked to the National Minimum Dataset and Laboratory Claims collection. WHO Methodology's Anatomical Therapeutic Chemical method's classification was used to characterise the SGAs dispensed. RESULTS: Of the 25,603 new users dispensed SGAs, 63.5% received glycaemic control monitoring at least once during the study period. Of these, only 20.1% were monitored at baseline, 38.7% were monitored for glycaemic control within the first 90 days. Glycaemic control monitoring within the first 180days increased to more than half (57.5%) of the SGA new users. Proportion of individuals monitored were independent (χ2=6.1; P=0.4) of pre-post bpacnz recommendation. CONCLUSIONS: Blood glucose monitoring was underutilized in new SGA users. No significant improvement in glycaemic control monitoring was observed after the 2007 bpacnz consensus statement release at baseline, 90days and at 180 days. Prescribers must be cautioned about the metabolic risks posed by SGAs and recommend glycaemic control monitoring.

Time-to-First Discontinuation, Adherence and Persistence in New Users of Second-Generation Antipsychotics.

Consensus guidelines which are applicable in New Zealand and worldwide recommend that the duration of exposure to antipsychotics not exceed 12 weeks, unless justified for mental illnesses like schizophrenia and severe psychotic symptoms which require longer treatment. There has been limited information on time-to-first discontinuation (TTFD) for second-generation antipsychotics (SGAs) in a real world population setting in older people. The study objective was to compare TTFD, adherence, and persistence for individual SGA new users among people 65 years and older. A cohort of 30,297 SGA new users was followed up for antipsychotic discontinuation from January 1, 2006, to December 31, 2012. Data for oral formulations were extracted using health care databases from the New Zealand Ministry of Health. The TTFD, adherence, and persistence were defined using (dispensing gap ≥ 91 days, variable medication possession ratio ≥ 0.8, and gap duration < 91 days between refills), respectively. Kaplan-Meier curves and Cox regression analysis were used to estimate and adjust for outcomes. The overall TTFD in SGA new users was 192.3 days (95% confidence interval [CI], 177.6-206.9), mean age at dispensing was 80.9 years (SD, 8.1 years), and 60.3% were women. The TTFD for was shortest for risperidone, 101.3 days (95% CI, 85.0-117.7; P = 0.03) compared with clozapine, 68.3 days (95% CI: 43.7, 92.9). The adjusted all-cause TTFD risk for risperidone, olanzapine, quetiapine, or ziprasidone (hazard ratios, 0.54, 0.29, 0.22, and 0.08, respectively) was significantly lower than clozapine. The TTFD risk in the nonadherent compared with the adherent group was more than 3 times.

Geographic variation in psychotropic drug utilisation among older people in New Zealand.

AIM: To examine psychotropic drug utilisation in older people in New Zealand by age, sex, health board domicile and deprivation status. METHODS: A repeated cross-sectional analysis of population-based drug utilisation data stratified by age, sex, ethnicity, health board and deprivation status was conducted from 2005 to 2013. RESULTS: Psychotropic utilisation increased between 2005 and 2013 (ranging from 7.0 to 74.0%) across all the health boards. In people aged 85 years and above, the hypnotic and sedative prevalence ratio compared to the 65- to 69-year age group was 1.45 (95% CI 1.44, 1.46). Between 2005 and 2013, the antidepressants prevalence ratio increased (1.27 (95% CI 1.22, 1.33)) relative to anxiolytics. CONCLUSIONS: Overall psychotropic drug utilisation increased over time. Despite safety concerns, hypnotic and sedative utilisation increased in the oldest vulnerable group. Shifts from anxiolytics to antidepressants in some health boards were consistent with guidelines for extended indications of antidepressant drug use.

Temporal trends for donepezil utilization among older people.

To examine and characterize overall donepezil and concomitant utilization with ß-blockers, yearly, in older New Zealanders. Deidentified data from the Pharmaceutical claims database and the National Minimum Dataset were obtained for 2011 to 2013 from the Ministry of Health. Population-level data were extracted for donepezil and ß-blockers utilization, measured by defined daily dose (DDD) per thousand older people per day (TOPD). Donepezil utilization increased from 5.2 to 8.2 DDD/TOPD between 2011 and 2013. In 2011, the number of prevalent users was 4634, the mean age was 79.4±6.6 years and 57.5% were women. Highest use by age for donepezil was in those aged 85 years or older (2.3 DDD/TOPD), followed by those aged 80-84 years (2.2 DDD/TOPD). The mean utilization volumes were significantly lower for donepezil 5 mg (Student t-test=9.86; P<0.05) and 10 mg (10.90; P<0.05) in the 65- to 69-year age group compared with the 80- to 84-year age group, whereas the proportion of concomitant utilization of donepezil with ß-blockers decreased (17.9% to 5.1%). Donepezil utilization in DDD/TOPD increased by three-fifths between 2011 and 2013. Prescribers appear to be aware of the potential risk of bradycardia with the concomitant use of donepezil and ß-blockers.

Quality use of antipsychotic medicines inresidential aged care facilities in New Zealand.

INTRODUCTION Antipsychotic medicines are used regularly or when required in residential aged care facilities to treat symptoms of dementia, but have been associated with several adverse effects. AIM The aim of this study was to examine 'quality use' of antipsychotic medicines in residential aged care facilities in New Zealand, by surveying nurse managers. METHODS A cross-sectional survey was mailed to 318 nurse managers working in a nationally representative sample of aged care facilities. A purpose-developed, pre-tested, 22-item structured questionnaire was used to explore practice related to the quality use of antipsychotic medicines. RESULTS Overall, 31.4% of nurse managers responded to the survey. They mostly (88%) had ≥ 1 year's relevant work experience and 83% of facilities provided care for those within the range of 21 to 100 residents. Respondents reported that staff education on dementia management occurred early in employment. Two-thirds of participants reported non-pharmacological interventions were commonly used for managing challenging behaviours, while less than half (45%) cited administering antipsychotic medicine. Respondents reported 'managing behavioural symptoms' (81%) as one of the main indications for antipsychotic use. Frequently identified adverse effects of antipsychotic medicines were drowsiness or sedation (64%) and falls (61%). Over 90% reported general practitioners reviewed antipsychotic use with respect to residents' target behaviour 3-monthly, and two-thirds used an assessment tool to appraise residents' behaviour. DISCUSSION Staff education on dementia management soon after employment and resident 3-monthly antipsychotic medicine reviews were positive findings. However, a wider use of behavioural assessment tools might improve the care of residents with dementia and the quality use of antipsychotic medicines.

Donepezil Adherence, Persistence and Time to First Discontinuation in a Three-Year Follow-Up of Older People.

BACKGROUND: Donepezil is indicated for the management of mild to moderate dementia, particularly in Alzheimer's disease. Several studies have described low adherence rates with donepezil. AIM: To examine and measure donepezil adherence, persistence and time to first discontinuation in older New Zealanders. METHODS: An inception cohort of 1,999 new users of donepezil, aged 65 years or older, were identified from the Pharmaceutical Collections and National Minimum Dataset from 1 November 2010 to 31 December 2013. Kaplan-Meier curves and Cox regression analysis were used to estimate the cumulative probability and risk of time to first discontinuation of donepezil therapy. RESULTS: The mean age of the cohort was 79.5 ± 6.4 years and included 42.7% females. Adherence was high (89.0%), while the proportion of donepezil dispensings (81.0-32.5%) declined between 6 and 36 months. Persistence between the 1st and 6th dispensing visit decreased by 19.0%, and 11.0% of the total cohort had a gap of 31 days or more. The adjusted risk of time to first discontinuation in the non-adherent group was 2.2 times (95% CI 1.9-2.6) that of the adherent group. CONCLUSIONS: The non-adherent new donepezil users, on average, discontinued faster than the adherent group. Time to first discontinuation in this study was higher compared to discontinuation rates observed in clinical trials.

Psychotropic medicine utilization in older people in New Zealand from 2005 to 2013.

BACKGROUND: Psychotropic medicine utilization has increased worldwide among older people (aged 65 years or older), in relation to utilization of other medicines. OBJECTIVE: The aim of this population-level study was to describe and characterize the national utilization of psychotropic medicines in older people in New Zealand between 2005 and 2013. METHODS: Repeated cross-sectional analysis of population-level dispensing data was conducted from 1 January 2005 to 31 December 2013. Data on utilization of psychotropic medicines were extracted and categorized in accordance with the World Health Organization Collaborating Centre for Drug Statistics Methodology's Anatomical Therapeutic Chemical classification system. Utilization was measured in terms of the defined daily dose (DDD) per 1,000 older people per day (TOPD). RESULTS: Overall, utilization of psychotropic medicines showed a 22.5 % increase between 2005 and 2013. Utilization increased for antidepressants (from 81.9 to 110.4 DDD/TOPD), antipsychotics (from 6.8 to 8.7 DDD/TOPD) and hypnotics and sedatives (from 59.4 to 65.5 DDD/TOPD); in contrast, utilization of anxiolytics decreased (from 11.4 to 10.7 DDD/TOPD). Utilization of atypical antipsychotics increased (from 4.6 to 6.8 DDD/TOPD), with the highest percentage change in DDD/TOPD being contributed by olanzapine (112.1 %), while utilization of typical antipsychotics declined (from 2.0 to 1.5 DDD/TOPD). Utilization of tetracyclic antidepressants and venlafaxine grew rapidly by 1.5 and 4.5 times, respectively, between 2005 and 2013. Utilization of zopiclone was greater than that of other hypnotics in 2013. CONCLUSION: Utilization of psychotropic medicines in older people increased by one fifth between 2005 and 2013. Important findings of this study were that: (1) there was a marked increase in utilization of recently funded antidepressants; (2) utilization of atypical antipsychotics increased; (3) there was a move towards utilization of selective serotonin reuptake inhibitors; (4) utilization of zopiclone remained high; and (5) low, standard and high DDD utilization all increased with time.

Drug Use Pattern with Standard Indicators in Jos University Teaching Hospital Nigeria

Background: Drug use pattern is assessed through prescribers; dispensers; and patients.The indicators used formonitoring include; health-facility; prescribing and patient care indicators. Objectives: The study was aimed at determining the drug use pattern by measuring core indicators in Jos University Teaching Hospital (JUTH); Nigeria; from 2010 to 2011; and to compare findings with similar institutions globally.Methods: Drug-specific analysis employed research tools using nine-item questionnaires; checklists and standard patient care forms. Data was obtained from patients who visited the hospital; within the period of thisstudy.Results: The study revealed that out of the total drugs prescribed; 85.3 were dispensed and the average number of drugs per prescription was three. About 70.2 of drugs were prescribed by generic names while therest were by brand names. Drugs prescribed from the hospital formulary were 88 with antibiotics being themost prescribed (35.3) while the least prescribed were injections (9) with no significant variation (p0.05)for the indicators measured during the period. Responses to questions on drug use produced positive results(85) in six out of the nine research items. Average consultation time was 11.33 minutes and dispensing timegave 3.53 minutes.Conclusion: The drug use pattern in JUTH was satisfactory compared to national and international findings. The core indicators measured underscored the need for pharmacists to provide drug information and counseling needs to patients and could serve as basis for further studies on drug use for hospitals in resource limited settings. Conclusion: The drug use pattern in JUTH was satisfactory compared to national and international findings. Thecore indicators measured underscored the need for pharmacists to provide drug information and counseling needs to patients and could serve as basis for further studies on drug use for hospitals in resource limited settings

Analysis of some biochemical and haematological parameters for Mucuna pruriens (DC) seed powder in male rats.

The biochemical and haematological effects of the seed powder of Mucuna pruriens in male rats were evaluated to establish some biological properties of this potential biopesticide currently undergoing investigation. The result showed that Mucuna pruriens seed extract produced a significant (p<0.05) increase in white blood cell (WBC) count, as well as in bilirubin concentrations, alkaline phosphatase (ALP), protein and creatinine levels measured. Alanine aminotransferase (ALT) and aspartate aminotransferase (AST) were significantly reduced (P<0.05) in comparison with the experimental control. PCV, Hb, albumin level and WBC differential counts gave no significant difference between treated and control groups. The results revealed metabolic imbalance in the rats which suggests a mild cholestasis effect of the extract.