[Show abstract][Hide abstract] ABSTRACT: Whilst multimorbidity is more prevalent with increasing age, approximately 30% of middle-aged adults (45-64 years) are also affected. Several prescribing criteria have been developed to optimise medication use in older people (≥65 years) with little focus on potentially inappropriate prescribing (PIP) in middle-aged adults. We have developed a set of explicit prescribing criteria called PROMPT (PRescribing Optimally in Middle-aged People's Treatments) which may be applied to prescribing datasets to determine the prevalence of PIP in this age-group.
A literature search was conducted to identify published prescribing criteria for all age groups, with the Project Steering Group (convened for this study) adding further criteria for consideration, all of which were reviewed for relevance to middle-aged adults. These criteria underwent a two-round Delphi process, using an expert panel consisting of general practitioners, pharmacists and clinical pharmacologists from the United Kingdom and Republic of Ireland. Using web-based questionnaires, 17 panellists were asked to indicate their level of agreement with each criterion via a 5-point Likert scale (1 = Strongly Disagree, 5 = Strongly Agree) to assess the applicability to middle-aged adults in the absence of clinical information. Criteria were accepted/rejected/revised dependent on the panel's level of agreement using the median response/interquartile range and additional comments.
Thirty-four criteria were rated in the first round of this exercise and consensus was achieved on 17 criteria which were accepted into the PROMPT criteria. Consensus was not reached on the remaining 17, and six criteria were removed following a review of the additional comments. The second round of this exercise focused on the remaining 11 criteria, some of which were revised following the first exercise. Five criteria were accepted from the second round, providing a final list of 22 criteria [gastro-intestinal system (n = 3), cardiovascular system (n = 4), respiratory system (n = 4), central nervous system (n = 6), infections (n = 1), endocrine system (n = 1), musculoskeletal system (n = 2), duplicates (n = 1)].
PROMPT is the first set of prescribing criteria developed for use in middle-aged adults. The utility of these criteria will be tested in future studies using prescribing datasets.
BMC Health Services Research 10/2014; 14(1):484. DOI:10.1186/s12913-014-0484-6 · 1.71 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Background
Comorbid conditions may be related (concordant) or unrelated (discordant) to diabetes. Comorbidity in patients with type 2 diabetes (T2DM) is associated with reduced health-related quality of life (HRQoL) and self-care.
To examine the impact of comorbidity on HRQoL and self-care in T2DM patients attending an outpatient setting.
A cross-sectional questionnaire was sent to 498 patients with T2DM, aged 25–80 years, previously attending (August 2011–July 2012) an outpatient diabetes service in a Dublin hospital. The EuroQoL-5 Dimension (EQ-5D) and a modified summary of diabetes self-care activities scale were used to assess HRQoL and self-care, respectively. Comorbidity was assessed using a simplified version of the self-administered comorbidity Questionnaire. Mann–Whitney and Kruskal–Wallis tests were used to examine the association between EQ-5D index scores or self-care, and the number and type of comorbidities. Multiple linear regression, adjusting for age and sex, was used to examine the association between EQ-5D score, comorbidity score and type.
EQ-5D scores decreased with an increasing number of comorbidities and with discordant comorbidity (P = 0.0001). Comorbidity type was associated with physical activity. The highest level of physical activity was reported in respondents with no comorbidity (median 4.5 IQR 3-6), while the lowest was in patients with both concordant and discordant comorbidity (median 2.5 IQR 0–5).
Health professionals should be aware of the fall in HRQoL associated with comorbidity. This should be taken into account in the management of patients. Patients with discordant comorbidity should be advised and supported to maintain levels of physical activity.
Irish Journal of Medical Science 08/2014; 184(3). DOI:10.1007/s11845-014-1190-4 · 0.83 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Background:
Few studies have investigated regional variation in medication-taking behaviour. The purpose of this study was to investigate whether there are regional differences in non-persistence and non-adherence to oral anti-hyperglycaemic agents in patients initiating therapy and examine if any association exists between different types of comorbidity in terms of medication-taking behaviour.
The Irish Health Services Executive (HSE) pharmacy claims database was used to identify new users of metformin or sulphonylureas, aged ≥25 years, initiating therapy between June 2009 and December 2010. Non-persistence and non-adherence were examined up to 12 months post-initiation. Comorbidity was assessed using modified RxRisk and RxRisk-V indices, and classified as either concordant and/or discordant with diabetes. Adjusted hazard ratios (HRs) and 95% confidence intervals (95% CIs) for non-persistence were determined in relation to both HSE region and comorbidity type using Cox proportional hazards model, adjusting for age, sex and initial OAH prescribed. Logistic regression analysis, adjusting for these covariates, was used to determine the adjusted odds ratios (ORs) and 95% CIs for non-adherence for both HSE region and comorbidity type.
Results showed little overall difference between regions. The largest reduction for both non-persistence (HR 0.86, 95% CI 0.80, 0.94) and non-adherence (OR 0.83, 95% CI 0.74, 0.93) was observed in the south. Any comorbidity was associated with a reduced risk of non-persistence and non-adherence.
Interventions to optimise medication-taking in patients with T2DM should be implemented nationally to improve the overall level of adherence and persistence, especially in patients with no comorbidity.
Irish Journal of Medical Science 05/2014; 184(2). DOI:10.1007/s11845-014-1132-1 · 0.83 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Background
Comorbidity in patients with diabetes is associated with poorer health and increased cost. The aim of this study was to investigate the prevalence and ingredient cost of comorbidity in patients ≥ 65 years with and without medication treated type 2 diabetes using a national pharmacy claims database.
The Irish Health Service Executive Primary Care Reimbursement Service pharmacy claims database, which includes all prescribing to individuals covered by the General Medical Services scheme, was used to identify the study population (≥ 65 years). Patients with medication treated type 2 diabetes (T2DM) were identified using the prescription of oral anti-hyperglycaemic agents alone or in combination with insulin as a proxy for disease diagnosis. The prevalence and ingredient prescribing cost of treated chronic comorbidity in the study population with and without medication treated T2DM were ascertained using a modified version of the RxRiskV index, a prescription based comorbidity index. The association between T2DM and comorbid conditions was assessed using logistic regression adjusting for age and sex. Bootstrapping was used to ascertain the mean annual ingredient cost of treated comorbidity. Statistical significance at p < 0.05 was assumed.
In 2010, 43165 of 445180 GMS eligible individuals (9.7%) were identified as having received medication for T2DM. The median number of comorbid conditions was significantly higher in those with T2DM compared to without (median 5 vs. 3 respectively; p < 0.001). Individuals with T2DM were more likely to have ≥ 5 comorbidities when compared to those without (OR = 2.82, 95% CI = 2.76-2.88, p < 0.0001). The mean annual ingredient cost for comorbidity was higher in the study population with T2DM (€1238.67, 95% CI = €1238.20 - €1239.14) compared to those without the condition (€799.28, 95% CI = €799.14 - € 799.41).
Individuals with T2DM were more likely to have a higher number of treated comorbid conditions than those without and this was associated with higher ingredient costs. This has important policy and economic consequences for the planning and provision of future health services in Ireland, given the expected increase in T2DM and other chronic conditions.
BMC Health Services Research 01/2013; 13(1):23. DOI:10.1186/1472-6963-13-23 · 1.71 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Optimization of drug prescribing in older populations is a priority due to the significant clinical and economic costs of drug-related illness. This study aimed to: (i) estimate the prevalence of potentially inappropriate prescribing (PIP) in a national Irish older population using European specific explicit prescribing criteria; (ii) investigate the association between PIP, number of drug classes, gender and age and; (iii) establish the total cost of PIP.
This was a retrospective national population study (n= 338 801) using the Health Service Executive Primary Care Reimbursement Service (HSE-PCRS) pharmacy claims database. The HSE-PCRS uses the WHO Anatomical Therapeutic Chemical (ATC) classification system and details of every drug dispensed and claimants' demographic data are available. Thirty PIP indicators (STOPP) were applied to prescription claims for those >or=70 years in Ireland in 2007. STOPP is a physiological system based screening tool of older persons' potentially inappropriate prescriptions assessing drug-drug and drug-disease interactions, dose and duration.
In our study population PIP prevalence was 36% (121 454 claimants). The main contributors to this were: 56 560 (17%) prescribed proton pump inhibitors at maximum therapeutic dose for >8 weeks, 29 691 (9%) prescribed non-steroidal anti-inflammatories for >3 months, 17 676 (5%) prescribed long-acting benzodiazepines for >1 month and 16 201 (5%) prescribed duplicate drugs. The main determinant of PIP was polypharmacy. The likelihood of PIP increased with a significant linear and quadratic trend (P < 0.0001) with the number of drug classes.The maximum net ingredient cost of PIP was estimated to be euro38 664 640. Total PIP expenditure was estimated to be euro45 631 319, 9% of the overall expenditure on pharmaceuticals in those >or=70 years in 2007.
The findings identify a high prevalence of PIP in Ireland with significant cost consequences.
British Journal of Clinical Pharmacology 05/2010; 69(5):543-52. DOI:10.1111/j.1365-2125.2010.03628.x · 3.88 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: To examine prescription patterns of nonsteroidal anti-inflammatory drugs (NSAIDs) or analgesics in patients prescribed chronic rofecoxib treatment prior to withdrawal from the Irish market, and to determine the impact on proton pump inhibitor (PPI) co-prescription.
Using a national prescribing database, adults (> or =16 years) prescribed rofecoxib for > or =3 months, but not analgesics, from January to September 2004 were identified. A longitudinal prescribing history was used to determine switching patterns to other cyclooxygenase (COX)-2 inhibitors, NSAIDs or analgesics during 3 and 12 months after withdrawal. Concomitant PPI prescription was examined. Logistic regression was used to determine the likelihood of switching to a COX-2 inhibitor vs. nonselective NSAID and factors influencing concomitant PPI prescription.
After rofecoxib withdrawal, 30.2% (1558) and 17.9% (922) of the 5155 study subjects received no further NSAID prescription during 3 and 12 months, respectively. During the 12-month period, approximately one-third of NSAID prescriptions were for <3 months; 40.7% (2096) received sequential prescriptions for different NSAIDs. Co-prescription of analgesics occurred in 49.3% (2539) of subjects. Neither age nor gender influenced the type of NSAID prescribed in the 12 months post rofecoxib withdrawal. PPI prescription increased by 5.5% during the study, associated with use of nonselective NSAIDs, prior use of PPIs and increasing age.
The majority of those receiving chronic rofecoxib therapy were prescribed either no further NSAID or short-term NSAID therapy only during the 12 months post withdrawal, which suggests the subsequent controversy may have encouraged prescribers to adhere more closely to published guidelines.
British Journal of Clinical Pharmacology 10/2007; 64(4):536-41. DOI:10.1111/j.1365-2125.2007.02918.x · 3.88 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: To characterize patients initiated on nonsteroidal anti-inflammatory drugs (NSAIDs), pre and postrofecoxib withdrawal, by age, gender and concomitant cardiovascular (CV) therapy.
A national primary care prescription database was used to identify patients who initiated NSAID therapy pre and postrofecoxib withdrawal. Patients receiving CV therapy were identified in the same periods also. Adjusted odds ratios (OR) and 95% confidence intervals are presented.
Female patients [OR = 1.15 (1.11, 1.19)], those over 65 years [OR = 2.76 (2.65, 2.86)] and those at CV risk [OR = 1.72 (1.67, 1.79)] were more likely to start on celecoxib (over a nonselective NSAID) than male patients, those under 65 years and those not at CV risk. Similar results were found for rofecoxib and nimesulide. Post-withdrawal analysis showed results comparable to the pre-withdrawal period.
The results highlight a possible uncertainty experienced by prescribers of treatment alternatives available and a lack of unbiased information at this time for at-risk groups.
British Journal of Clinical Pharmacology 05/2007; 63(4):494-7. DOI:10.1111/j.1365-2125.2006.02784.x · 3.88 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Atrial fibrillation is the commonest cardiac rhythm disturbance and is an independent risk factor for stroke; however, use of oral antithrombotic therapy is reported to be suboptimal in clinical practice.
The aim of the study was to evaluate the prescribing rates of oral antithrombotic therapy in patients with atrial fibrillation to determine if prescribing patterns reflected published clinical guidance.
Patients with atrial fibrillation, admitted to hospital over a 12-week period were identified and their antithrombotic therapy regimen was analysed using statistical methods.
Although 87/100 patients identified were prescribed OAT, the regimen was suboptimal in 35 patients. Patients aged 75 years and older were more likelyto be receiving suboptimal oral antithrombotic treatment compared with younger patients
The benefits and suitability of oral antithrombotic therapy for patients of all ages need to be more comprehensively communicated to prescribers.
Irish Journal of Medical Science 06/2006; 175(2):46-9. DOI:10.1007/BF03167949 · 0.83 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: To evaluate the effect of publicity surrounding the Women's Health Initiative (WHI) and Million Women (MW) studies on prescribing of all hormone replacement therapy (HRT) preparations and bisphosphonates in Ireland.
The General Medical Services (GMS) prescription database was used to identify the study population. Prescriptions were identified for HRT and bisphosphonate preparations [using WHO Anatomical Therapeutic Chemical (ATC) classification codes] in female patients aged 45-69 years in Ireland during a 4-year study period (January 2001-December 2004). Prescription rates were calculated monthly. Prevalence and incidence of HRT use was examined.
There was a significant reduction in prevalence for all HRT preparations following the WHI trial (test for change in trend p<0.0001), which persisted after the MW study. The incidence of combined oestrogen/progestogen HRT declined after the WHI trial (test for change in trend p=0.004). Bisphosphonate prescribing showed a significant increase throughout the study period (p<0.0001).
The findings suggest that coverage surrounding the publication of clinical trials appears to have had a negative impact on the rate of HRT prescribing. The findings regarding the coincident increase in use of bisphosphonates may suggest that prescribers and users were less likely to regard HRT as an appropriate therapy in the management of osteoporosis for some time before guidance was issued by the regulatory authorities.
European Journal of Clinical Pharmacology 04/2006; 62(4):307-10. DOI:10.1007/s00228-005-0083-x · 2.97 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Paracetamol-containing combination analgesics are widely prescribed but the use of paracetamol/dextropropoxyphene (co-proxamol) is particularly controversial. We aim to examine the prescribing patterns of the paracetamol-containing analgesics in Ireland.
A national primary care prescribing database was used to investigate patterns of usage. Twenty-six thousand three hundred and eighteen patients who were new to therapy with paracetamol and paracetamol-containing analgesics between January and June 2002 were identified as follows: no previous analgesic medication in the 6 months prior to enrolment into the study, and followed up for at least 12 months from the time of enrolment. Duration of therapy and the number of prescriptions received post enrolment were analyzed according to age. Odds ratios for receiving long-term (>1 month) compared with short-term (1 month) prescriptions for co-proxamol, paracetamol only or a paracetamol combination-type analgesic were calculated for women vs. men, and in those aged over 65 vs. those aged under 65 years.
Co-proxamol was the most commonly prescribed analgesic, accounting for 42% of all prescriptions dispensed during 2003. Long-term use of paracetamol-containing analgesic preparations was uncommon, with 56.7% receiving only 1 month's prescription during the study period. However, women (OR = 1.18, 95% CI 1.07, 1.28, P < 0.0001) and those over 65 years (OR = 1.71, 95% CI 1.57, 1.86, P < 0.0001) were more likely to receive a follow-up prescription for co-proxamol, but also for paracetamol (women, OR = 1.28, 95% CI 1.16, 1.39; over 65 year olds, OR = 2.67, 95% CI 2.44, 2.93) and the paracetamol combinations (women, OR = 1.33, 95% CI 1.20, 1.47; over 65 year olds, OR = 1.69, 95% CI 1.53, 1.87).
Co-proxamol was the most commonly prescribed paracetamol-containing analgesic preparation in Ireland. The results may indicate inappropriate use in primary care.
British Journal of Clinical Pharmacology 12/2005; 60(6):648-52. DOI:10.1111/j.1365-2125.2005.02500.x · 3.88 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: To monitor statin prescribing trends over time in order to determine whether prescribers were influenced by study results and/or clinical guidelines in terms of type and dosage of statin prescribed.
The GMS (General Medical Services) prescription database in Ireland was used to identify a cohort of patients, prescribed statins, in order to investigate prescribing trends from January 1998-December 2002. Statin prescribing rates for patients with ischaemic heart disease and diabetes were compared with rates in the general GMS population. Logistic regression analysis was used in patients with ischaemic heart disease and diabetes and adjusted odds ratios and 95% confidence intervals presented.
Increased statin prescribing over time was noted (test for linear trend P < 0.0001). Pravastatin was the most frequently prescribed, followed by atorvastatin; simvastatin and fluvastatin showed lower rates of prescribing. Atorvastatin showed the greatest increased rate over time. An increase in the overall dose prescribed (test for trend P < 0.01) was chiefly due to increases in pravastatin dose, but doses were still below those recommended from clinical trials. Statins were prescribed more frequently in patients with ischaemic heart disease and diabetes, 44% (95% CI 43-45%) compared with the total GMS population, 7.7% (95% CI 7.6-7.8%), by December 2002. However, statins were only prescribed to 52% (95% CI 51-53%) of ischaemic heart disease patients and 40% (95% CI 39-41%) of patients with diabetes by December 2002. Patients aged 45-64 years were more likely to receive statins, compared with those aged 65 years and older.
These findings suggest that the beneficial effects of statins shown in clinical studies may not be achieved in practice.
British Journal of Clinical Pharmacology 03/2005; 59(2):227-32. DOI:10.1111/j.1365-2125.2004.02256.x · 3.88 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: To quantify usage of COX-2 inhibitors compared with nonselective NSAIDs and to determine their impact (including financial) on the co-prescription of antipeptic ulcer (anti-PU) drugs.
The Irish General Medical Services prescription database (covering 1.2 million people) was examined for NSAID prescriptions during December 1999-November 2001. NSAID users were excluded during the first 6 months. During the next 12 months (study period) patients on NSAIDs (>or= 3 prescriptions) were identified. The study period and final 6 months provided data on co-prescription of anti-PU drugs. Age, gender, number of concomitant prescriptions, co-prescribing of anti-PU drugs and monthly cost were evaluated for 8 NSAIDs (n= 4 non-selective NSAIDs and n= 4 COX-2 inhibitors) and odds ratios (OR) calculated using logistic regression.
COX-2 inhibitors were prescribed more frequently in older, female patients and those receiving multiple medications. After adjustment for age, gender and polypharmacy, anti-PU drugs were prescribed more frequently with COX-2 inhibitors (OR = 1.31 (1.23,1.40)). COX-2 inhibitors were up to 10-fold more expensive, median monthly costs (including anti-PU drugs) ranging from Euros 34.61 (COX-2 inhibitors) to Euros 3.26 (nonselective NSAIDs).
Since COX-2 inhibitors are associated with increased rates of co-prescription of anti-PU drugs and are more expensive than non-selective NSAIDs, these results suggest that the expected cost-savings with COX-2 inhibitors may not be occurring in practice.
British Journal of Clinical Pharmacology 04/2004; 57(3):337-43. DOI:10.1046/j.1365-2125.2003.02012.x · 3.88 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Non-steroidal anti inflammatory drugs (NSAIDs) are thought to account for almost 25% of all reported adverse drug reactions, primarily gastrointestinal (GI) toxicity. Selective cyclo-oxygenase-2 (COX-2) inhibitors have been shown to preferentially inhibit activity of the COX-2 enzyme, which maintains anti-inflammatory activity but reduces GI toxicity.
To determine the degree of switching from non-selective NSAIDs to COX-2 inhibitors and to examine the factors that were associated with switching.
The General Medical Services prescription database (1.2 million people) was examined for NSAID prescriptions from December 1999 through November 2001. All those receiving non-selective NSAIDs and those switching to selective COX-2 inhibitors after at least 1 month on a non-selective NSAID were identified (non-switchers and switchers, respectively). Age, sex, dose of non-selective NSAID and co-prescribing of anti-peptic ulcer (anti-PU) drugs were considered between switchers and non-switchers, and odds ratios (OR) calculated using logistic regression. The effect of chronic use (> or =3 months prescription of a non-selective NSAID during the study period) on switching was also evaluated.
A total of 81,538 of 480,573 patients (17%) initially prescribed non-selective NSAIDs were switched to COX-2 inhibitors during the study. The elderly (65 years or older) were more likely to be switched to a COX-2 inhibitor [OR=1.81, 95% confidence interval (CI) 1.79, 1.84]. Women were also more likely to be switched to COX-2 inhibitor therapy (OR=1.25, 95% CI 1.23, 1.27). Previous but not subsequent prescribing of anti-PU drugs was also associated with switching. Chronic users showed similar switching patterns.
Prescribers are more likely to switch older female patients and those with a past history of peptic ulcers from non-selective NSAIDs to COX-2 inhibitors. This suggests that doctors take risk factors into consideration when prescribing NSAIDs. The relatively low rate of switching may suggest that prescribers still have concerns over the place of COX-2 inhibitors and reserve their use to those patients particularly at risk of NSAID-induced GI toxicity.
European Journal of Clinical Pharmacology 11/2003; 59(8-9):645-9. DOI:10.1007/s00228-003-0661-8 · 2.97 Impact Factor