Rethinking prescribing in the United States.
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ABSTRACT:
SUBMITTER: Ellner A
PROVIDER: S-EPMC293000 | biostudies-literature | 2003 Dec
REPOSITORIES: biostudies-literature
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Rethinking prescribing in the United States.
BMJ (Clinical research ed.) 20031201 7428
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Project description:Importance:Benzodiazepines are implicated in a growing number of overdose-related deaths. Objectives:To quantify patterns in outpatient benzodiazepine prescribing and to compare them across specialties and indications. Design, Setting, and Participants:This serial cross-sectional study (January 1, 2003, through December 31, 2015) used nationally representative National Ambulatory Medical Care Survey data. The yearly population-based sample of outpatient visits among adults, ranging from 20 884 visits in 2003 (representing 737 million visits) to 24 273 visits in 2015 (representing 841 million visits) was analyzed. Prescribing patterns were examined by specialty and indication and used to calculate the annual coprescribing rate of benzodiazepines with other sedating medications. Data were analyzed from July 1, 2017, through November 30, 2018. Main Outcomes and Measures:Annual benzodiazepine visit rate. Results:Among the 386 457 ambulatory care visits from 2003 through 2015, a total of 919 benzodiazepine visits occurred in 2003 and 1672 in 2015, nationally representing 27.6 million and 62.6 million visits, respectively. The benzodiazepine visit rate doubled from 3.8% (95% CI, 3.2%-4.4%) to 7.4% (95% CI, 6.4%-8.6%; P < .001) of visits. Visits to primary care physicians accounted for approximately half of all benzodiazepine visits (52.3% [95% CI, 50.0%-54.6%]). The benzodiazepine visit rate did not change among visits to psychiatrists (29.6% [95% CI, 23.3%-36.7%] in 2003 to 30.2% [95% CI, 25.6%-35.2%] in 2015; P = .90), but increased among all other physicians, including primary care physicians (3.6% [95% CI, 2.9%-4.4%] to 7.5% [95% CI, 6.0%-9.5%]; P < .001). The benzodiazepine visit rate increased slightly for anxiety and depression (26.6% [95% CI, 22.6%-31.0%] to 33.5% [95% CI, 28.8%-38.6%]; P = .003) and neurologic conditions (6.8% [95% CI, 4.8%-9.5%] to 8.7% [95% CI, 6.2%-12.1%]; P < .001), but more so for back and/or chronic pain (3.6% [95% CI, 2.6%-4.9%] to 8.5% [95% CI, 6.0%-11.9%]; P < .001) and other conditions (1.8% [95% CI, 1.4%-2.2%] to 4.4% [95% CI, 3.7%-5.2%]; P < .001); use did not change for insomnia (26.9% [95% CI, 19.3%-36.0%] to 25.6% [95% CI, 15.3%-39.6%]; P = .72). The coprescribing rate of benzodiazepines with opioids quadrupled from 0.5% (95% CI, 0.3%-0.7%) in 2003 to 2.0% (95% CI, 1.4%-2.7%) in 2015 (P < .001); the coprescribing rate with other sedating medications doubled from 0.7% (95% CI, 0.5%-0.9%) to 1.5% (95% CI, 1.1%-1.9%) (P < .001). Conclusions and Relevance:The outpatient use of benzodiazepines has increased substantially. In light of increasing rates of overdose deaths involving benzodiazepines, understanding and addressing prescribing patterns may help curb the growing use of benzodiazepines.
| S-EPMC6484578 | biostudies-literature
Project description:In this national cohort of older adults residing long-term in US nursing homes between 2013 and 2017, we calculated period prevalence estimates for antibiotic prescribing, rates of prescribing, and days of therapy. Among 1 375 062 residents, 66.2% were prescribed at least 1 antibiotic during the nursing home stay. The most prevalent antibiotic classes were fluoroquinolones, sulfonamides and related agents, and first-generation cephalosporins. Levofloxacin, ciprofloxacin, and sulfamethoxazole-trimethoprim were the most prevalent antibiotics. These results can inform antibiotic stewardship interventions to reduce antibiotic overprescribing, improve appropriateness, and reduce related adverse outcomes in nursing homes.
| S-EPMC10428191 | biostudies-literature
Project description:Acne vulgaris is the most common reason for pediatric patients and third most common reason for adult patients to seek care from a dermatologist in the US. However, referring providers may be reluctant to initiate patients on acne treatment or certain prescriptions. We assessed over-the-counter (OTC) and prescription acne (antibiotic and non-antibiotic) treatment rates to characterize differences by patient demographics and provider specialty. The National Ambulatory Medical Care Survey (NAMCS) was analyzed for all acne therapies prescribed for at least 10 unweighted visits between 1993 and 2016 (most recent years available). Prescription rates varied by age, with younger patients more likely to receive a prescription; insurance status, with privately insured patients more likely to receive a prescription; and across and within specialties, with dermatologists more likely to recommend a prescription medication than family medicine and pediatric providers. Among all forms of antibiotics for acne vulgaris, oral minocycline was the most commonly prescribed antibiotic by dermatologists, followed by oral doxycycline. Oral minocycline was also the most common antibiotic prescribed by family physicians, followed by oral doxycycline and oral clindamycin, respectively. Pediatricians appeared to be less likely to prescribe oral antibiotics for acne. The OTC topical antimicrobial benzoyl peroxide was the most utilized drug for acne among pediatricians, and it was also the most commonly recommended OTC drug for acne among dermatologists, family physicians, and pediatricians.
| S-EPMC9952425 | biostudies-literature
Project description:National Ambulatory Medical Care Survey data were used to assess outpatient macrolide prescribing and selection. Conditions for which macrolides are firstline therapy represented 5% of macrolide prescribing. Family practitioners selected macrolides for children more frequently than pediatricians. Macrolides are an important antibiotic stewardship target.
| S-EPMC5729700 | biostudies-literature
Project description:BackgroundDentists prescribe approximately 10% of outpatient antibiotics, but little is known about dentists' antibiotic prescribing patterns. The authors conducted a study to characterize prescribing by dentists according to antibiotic agent and category, patient demographic characteristics, and geographic region in the United States.MethodsThe authors identified oral antibiotic prescriptions dispensed during 2013 in the Xponent (QuintilesIMS) database. The authors used the total number of prescriptions and county-level census population denominators to calculate prescribing rates. In addition, the authors analyzed prescribing according to individual agent, drug category, and patient demographic characteristics and the total number of prescriptions calculated for general dentists overall.ResultsDentists prescribed 24.5 million courses of antibiotics in 2013, a prescribing rate of 77.5 prescriptions per 1,000 people. Penicillins were the most commonly prescribed antibiotic category. Dentists prescribed most antibiotics for adults older than 19 years. The Northeast census region had the highest prescribing rate per 1,000 people. The District of Columbia had the highest prescribing rate of 99.5 per 1,000 people, and Delaware had the lowest prescribing rate of 50.7 per 1,000 people.ConclusionsDentists prescribe large quantities of antibiotics in outpatient settings, and there is considerable geographic variability. Additional study is needed to better understand the reasons for this variability and identify areas of possible intervention and improvement.Practical implicationsContinued efforts to combat antibiotic resistance will require all prescribers, including dentists, to examine prescribing behaviors for appropriateness and the effectiveness of guidelines to identify opportunities to optimize antibiotic use.
| S-EPMC6814255 | biostudies-literature
Project description: Not available
| S-EPMC4100547 | biostudies-literature
Project description:BACKGROUND:Antibiotic prescribing practices among general dentists and dental specialists in the United States remains poorly understood. The purpose of this study was to compare prescribing practices across dental specialties, evaluate the duration of antibiotics dentists prescribed, and determine variation in antibiotic selection among dentists. METHODS:The authors performed a retrospective cross-sectional analysis of dental care provider specialties linked to deidentified antibiotic claims data from a large pharmacy benefits manager during the 2015 calendar year. RESULTS:As a group, general dentists and dental specialists were responsible for more than 2.9 million antibiotic prescriptions, higher than levels for several other medical and allied health care provider specialties. Antibiotic treatment duration generally was prolonged and commonly included broad-spectrum agents, such as amoxicillin clavulanate and clindamycin. Although amoxicillin was the most commonly prescribed antibiotic among all dental specialties, there was substantial variation among other antibiotics each specialty selected. The most common antibiotic treatment durations were 7 and 10 days. CONCLUSIONS:This study's results demonstrate that dentists frequently prescribe antibiotics for prolonged periods and often use broad-spectrum antibiotics. Further studies are necessary to evaluate the appropriateness of these antibiotic prescribing patterns. PRACTICAL IMPLICATIONS:The clinically significant variation in antibiotic selection and treatment duration identified among all dental specialties in this study population implies that further research and guidance into the treatment of dental infections is necessary to improve and standardize antibiotic prescribing practices.
| S-EPMC5705569 | biostudies-literature
Project description:The prescription of opioid analgesics by dental professionals is widespread in the United States. Policy makers, government agencies, and professional organizations consider this phenomenon a growing public health concern. This study examined trends in the prescription of opioid analgesics for adults by dental professionals and associated factors in the United States. Data from the Medical Expenditure Panel Survey (1996-2013) were analyzed. Descriptive statistics were calculated separately for each year. Logistic regression analyses were conducted to estimate the overall trend during the period with and without adjusting for dental procedures and personal characteristics. Survey weights were incorporated to handle the sampling design. The prescription of opioid analgesics following dental care increased over time. After adjusting for sociodemographic factors, source of payment, and type of dental procedure, the odds ratio (OR) of prescribing opioid analgesics following a dental visit per each decade difference was 1.28 (95% confidence interval [CI], 1.19-1.38). Surgical, root canal, and implant procedures had the highest rates of opioid prescriptions and the greatest increases in rates over the study period. After adjusting for personal characteristics and type of dental procedure, the OR of receiving a prescription for opioids comparing blacks, Asians, and Hispanics to whites was 1.29 (95% CI, 1.17-1.41), 0.57 (95% CI, 0.47-0.70), and 0.84 (95% CI, 0.75-0.95), respectively. Opioid analgesic prescriptions following dental visits increased over time after adjusting for personal characteristics and type of dental procedure. The odds of receiving a prescription for opioids were higher for certain racial/ethnic minority groups. Knowledge Transfer Statement: This study highlights dental professionals prescribing practices of opioid analgesics by following dental treatments in the United States. With this knowledge, appropriate guidelines, protocols, and policies can be developed and implemented to address any inappropriate prescribing practices of opioid analgesics. In addition, this information could lead to an improvement in the prescribing practices of dental professionals and to evidence-based therapeutic decision making.
| S-EPMC5576054 | biostudies-literature
Project description:ImportancePrimary care clinicians find managing chronic pain challenging. Evidence of long-term efficacy of opioids for chronic pain is limited. Opioid use is associated with serious risks, including opioid use disorder and overdose.ObjectiveTo provide recommendations about opioid prescribing for primary care clinicians treating adult patients with chronic pain outside of active cancer treatment, palliative care, and end-of-life care.ProcessThe Centers for Disease Control and Prevention (CDC) updated a 2014 systematic review on effectiveness and risks of opioids and conducted a supplemental review on benefits and harms, values and preferences, and costs. CDC used the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) framework to assess evidence type and determine the recommendation category.Evidence synthesisEvidence consisted of observational studies or randomized clinical trials with notable limitations, characterized as low quality using GRADE methodology. Meta-analysis was not attempted due to the limited number of studies, variability in study designs and clinical heterogeneity, and methodological shortcomings of studies. No study evaluated long-term (≥1 year) benefit of opioids for chronic pain. Opioids were associated with increased risks, including opioid use disorder, overdose, and death, with dose-dependent effects.RecommendationsThere are 12 recommendations. Of primary importance, nonopioid therapy is preferred for treatment of chronic pain. Opioids should be used only when benefits for pain and function are expected to outweigh risks. Before starting opioids, clinicians should establish treatment goals with patients and consider how opioids will be discontinued if benefits do not outweigh risks. When opioids are used, clinicians should prescribe the lowest effective dosage, carefully reassess benefits and risks when considering increasing dosage to 50 morphine milligram equivalents or more per day, and avoid concurrent opioids and benzodiazepines whenever possible. Clinicians should evaluate benefits and harms of continued opioid therapy with patients every 3 months or more frequently and review prescription drug monitoring program data, when available, for high-risk combinations or dosages. For patients with opioid use disorder, clinicians should offer or arrange evidence-based treatment, such as medication-assisted treatment with buprenorphine or methadone.Conclusions and relevanceThe guideline is intended to improve communication about benefits and risks of opioids for chronic pain, improve safety and effectiveness of pain treatment, and reduce risks associated with long-term opioid therapy.
| S-EPMC6390846 | biostudies-literature
Project description:Importance:Small studies and anecdotal evidence suggest marked differences in the use of opioids after surgery internationally; however, this has not been evaluated systematically across populations receiving similar procedures in different countries. Objective:To determine whether there are differences in the frequency, amount, and type of opioids dispensed after surgery among the United States, Canada, and Sweden. Design, Setting, and Participants:This cohort study included patients without previous opioid prescriptions aged 16 to 64 years who underwent 4 low-risk surgical procedures (ie, laparoscopic cholecystectomy, laparoscopic appendectomy, arthroscopic knee meniscectomy, and breast excision) between January 2013 and December 2015 in the United States, between July 2013 and March 2016 in Canada, and between January 2013 and December 2014 in Sweden. Data analysis was conducted in all 3 countries from July 2018 to October 2018. Main Outcomes and Measures:The main outcome was postoperative opioid prescriptions filled within 7 days after discharge; the percentage of patients who filled a prescription, the total morphine milligram equivalent (MME) dose, and type of opioid dispensed were compared. Results:The study sample consisted of 129 379 patients in the United States, 84 653 in Canada, and 9802 in Sweden. Overall, 52 427 patients (40.5%) in the United States were men, with a mean (SD) age of 45.1 (12.7) years; in Canada, 25 074 patients (29.6%) were men, with a mean (SD) age of 43.5 (13.0) years; and in Sweden, 3314 (33.8%) were men, with a mean (SD) age of 42.5 (13.0). The proportion of patients in Sweden who filled an opioid prescription within the first 7 days after discharge for any procedure was lower than patients treated in the United States and Canada (Sweden, 1086 [11.1%]; United States, 98 594 [76.2%]; Canada, 66 544 [78.6%]; P < .001). For patients who filled a prescription, the mean (SD) MME dispensed within 7 days of discharge was highest in United States (247 [145] MME vs 169 [93] MME in Canada and 197 [191] MME in Sweden). Codeine and tramadol were more commonly dispensed in Canada (codeine, 26 136 patients [39.3%]; tramadol, 12 285 patients [18.5%]) and Sweden (codeine, 170 patients [15.7%]; tramadol, 315 patients [29.0%]) than in the United States (codeine, 3210 patients [3.3%]; tramadol, 3425 patients [3.5%]). Conclusions and Relevance:The findings indicate that the United States and Canada have a 7-fold higher rate of opioid prescriptions filled in the immediate postoperative period compared with Sweden. Of the 3 countries examined, the mean dose of opioids for most surgical procedures was highest in the United States.
| S-EPMC6727684 | biostudies-literature