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OBJECTIVE: Our study evaluated the association between initial opioid prescription duration and receipt of a repeat opioid prescription in children. METHODS: Eligible individuals were children between 1 and 17 years of age who enrolled in a Medicaid Managed Care plan and filled an incident opioid prescription during 2013 to 2018. An incident prescription was defined as receipt of an opioid analgesic without a prior use for 12 months. A repeat opioid prescription was defined as receipt of a subsequent opioid prescription within 30 days since the end of incident opioid prescription. A hierarchical multivariable logistic regression model was fitted to test the association between incident opioid prescription duration and the likelihood of receiving a repeat prescription. RESULTS: The cohort consisted of 17,086 children receiving an incident opioid prescription in which 6272 (36.7%) received 1 to 3 days' supply, 8442 (49.4%) received 4 to 7 days' supply, 1434 (8.4%) received 8 to 10 days' supply, and 938 (5.5%) received >10 days' supply. Of these incident opioid recipients, 1780 (10.4%) filled a repeat opioid prescription. The multilevel model results indicated that, children receiving 4 to 7 days' supply (adjusted odds ratio [aOR]: 0.98 {0.9 -1.1}), 8 to 10 days' supply (aOR: 1.03 [0.8-1.3]), and >10 days' supply (aOR: 0.85 [0.7-1.1]) had comparable likelihoods of receiving a repeat prescription as those receiving 1 to 3 days' supply. DISCUSSION: Nearly 10% of children who filled an opioid prescription for acute pain received a repeat prescription. Initial prescription duration was not associated with the risk of receiving a repeat prescription. [ABSTRACT FROM AUTHOR]

With the changing healthcare landscape, evaluating the care provision in ambulatory settings is vital to understand outpatient care. The national surveys such as the National Ambulatory Medical Care Survey (NAMCS) and the National Hospital Ambulatory Medical Care Survey (NHAMCS) are valuable resources to pharmacy researchers because of their availability and generalizability. With the recent focus on real-world data, the national surveys are critical in providing practice and policy evidence by evaluating ambulatory care, especially prescribing practices. The use of these surveys requires an understanding of the survey content, scope, complex sampling scheme, and analytical and research considerations. There are several methodological and practical considerations that make these national surveys useful to both novice and seasoned researchers. Although some generalized approaches are available for analyzing the national surveys, there is limited focus on the NAMCS and the NHAMCS. This paper provides an in-depth understanding of the NAMCS/NHAMCS, including methodological considerations for evaluating prescribing practices in ambulatory settings. [ABSTRACT FROM AUTHOR]

Millions of U.S. people have been heavily affected by opioids. In March 2023, the Food and Drug Administration approved naloxone as an over-the-counter medication. This has allowed more access to patients at high risk of opioid overdose. However, the patient's willingness to pay for naloxone at the pharmacy counter has not been assessed. This study aimed to characterize factors associated with the willingness to pay for naloxone among the patient group. A cross-sectional Qualtrics online panel survey instrument was developed. This survey was distributed to patients in the United States, aged ≥ 18 years, with any chronic pain and taking opioids. The survey included demographics, and clinical characteristics (pain assessment, opioid use, and knowledge of naloxone). In addition, willingness to pay was assessed using a 7-point Likert scale ranging from strongly disagree to strongly agree. An ordinal logistic regression model was used to examine demographic and clinical characteristics. A total of 549 subjects completed the survey (women [53.01%], white or Caucasian (83.61%), age mean [SD] 44 [13]). Women were associated with less willingness to pay (adjusted odds ratio [aOR] 0.685 [95% CI 0.478-0.983], P = 0.0403). Compared with the high household income group (≥ $150,000), low household income ≤ $25,000 (aOR 0.326 [95% CI 0.160-0.662], P = 0.0020) or income between $25,000 and 74,999 (aOR 0.369 [95% CI 0.207-0.657], P = 0.0007) was associated with less likelihood of willing to pay. Patients with a previous diagnosis of obstructive sleep apnea were associated with a higher likelihood of willingness to pay (aOR 1.685 [95% CI 1.138-2.496], P = 0.0092). Each unit increase in pain was also associated with a higher likelihood of willingness to pay (aOR 1.247 [95% CI 1.139-1.365], P < 0.0001). Demographics and clinical factors were associated with willingness to pay for naloxone. This study's findings are useful in the development of interventions to address pharmacy-based naloxone distribution programs. [ABSTRACT FROM AUTHOR]

• The study found three long-term adherence trajectories of oral disease-modifying agents (DMAs) in multiple sclerosis (MS). • The study found there was no difference in annualized relapse rates (ARR) across the three DMAs. • Adherence trajectory grouped as rapid decliners had a higher ARR than completely adherent patients. • The type of oral DMAs did not moderate the relationship between ARR and the adherence trajectory groups. Real-world effectiveness can vary across oral disease-modifying agents (DMAs) and their adherence trajectories in patients with multiple sclerosis (MS). However, previous studies have not considered longitudinal adherence patterns while evaluating oral DMAs. This study aimed to evaluate the association of oral DMAs and their adherence trajectories with annualized relapse rate (ARR) in patients with MS. This retrospective observational cohort study based on the 2015–2019 MarketScan Commercial Claims and Encounters Database involved continuous enrolled adults (18–64 years) with ≥1 MS diagnosis (ICD-9/10-CM:340/G35) and ≥ 1 oral DMA prescription. Patients were grouped into incident fingolimod (FIN), teriflunomide (TER), and dimethyl fumarate (DMF) users based on the index DMA with a one-year washout period. Annual DMA adherence trajectories based on the monthly Proportion of Days Covered (PDC) one year after treatment initiation were identified using Group-Based Trajectory Modeling (GBTM). The validated claims-based ARR was evaluated during the one-year follow-up period using generalized boosted model-based inverse probability treatment weights with negative binomial regression model. The study cohort consisted of 994 MS patients who initiated with FIN (23.0%), TER (22.3%), and DMF (54.7%) during the study period. GBTM grouped eligible patients into three adherence trajectories: complete adherers (59.2%), slow decliners (23.8%), and rapid decliners (17.0%). The proportion of complete adherers varied across the oral DMAs (FIN: 67.1%, TER: 55.4%, and DMF: 57.4%). The negative binomial regression modeling revealed that, while there was no difference in ARR across the three DMAs, rapid decliners (adjusted incidence rate ratio[aIRR]: 1.6, 95% CI: 1.1–2.4) had a higher rate of relapses compared to completely adherent patients. The type of oral DMAs did not moderate the relationship between ARR and the adherence trajectory groups. Adherence trajectories classified as rapid decliners were associated with a higher ARR than complete adherers after adjusting for their type of oral DMAs. Longitudinal medication adherence patterns are critical in reducing relapse rates in MS. [ABSTRACT FROM AUTHOR]

Background: Disease modifying agents (DMAs) are used to reduce relapses and decrease disability progression in Multiple Sclerosis (MS) patients. However, limited national level data exists regarding the prescribing patterns for MS, especially after the introduction of oral DMAs.Objective: This study examined the prescribing patterns and trends of DMAs using national level data and determined the factors associated with prescribing DMAs among MS patients in the United States.Methods: This cross-sectional study utilized 2006-2015 National Ambulatory Medical Care Survey (NAMCS) data to examine office-based visits involving MS (ICD-9-CM code 340). Descriptive weighted analyses were performed to assess the prescribing patterns of DMAs. Multivariable logistic regression model within the conceptual framework of Andersen Behavioral Model was used to determine the factors associated with prescribing of DMAs among MS patients.Results: An estimated 8.5 million (95% Confidence Interval [CI] 7.01-10.09 million) MS patient visits were identified from 2006 to 2015. During the ten-year study period, 3.84 million (45%) MS visits involved prescribing of DMAs. The majority of DMA prescriptions were injectables (78%), followed by infusions (11%) and orals (11%). Oral DMAs use increased (from 11% in 2010-2011 to 40% in 2014-2015), whereas the use of injectable DMAs decreased (from 96% in 2006-2007 to 52% in 2014-2015) during the study period. Multivariable analyses revealed that predisposing (age and region) and enabling (physician specialty) factors were significantly associated with prescribing of DMAs among MS patients. Visits to neurologists (Odds Ratio [OR] 6.61, 95% CI 3.66-11.93) were associated with higher odds of being prescribed with DMAs.Conclusion: During the ten-year study period, increasing use of oral DMAs and declining use of injectable DMAs was observed. Both predisposing and enabling factors influenced the prescribing of DMAs. With increasing availability of oral DMAs, the DMAs use is likely to increase among MS patients. [ABSTRACT FROM AUTHOR]

Objectives: This study examined the risk of all-cause-mortality in patients with Parkinson's Disease (PD) and comorbid depression using inappropriate atypical antipsychotics (AAPs), based on the 2015 American Geriatrics Society Beers criteria.Methods: A retrospective analysis of 2007-2010 Minimum Data Set linked Medicare data was conducted using a propensity-matched approach. The cohort included PD patients aged 65 years or older without schizophrenia or bipolar disorder who started AAPs. All patients had a diagnosis of comorbid depression. Risk of 6-month all-cause-mortality was compared across appropriate AAPs (aripiprazole, clozapine, or quetiapine) and inappropriate AAPs (olanzapine, asenapine, brexpiprazole, iloperidone, lurasidone, paliperidone, risperidone, or ziprasidone) using robust Cox regression models involving the matched cohort.Results: All-cause mortality rate was 15.65% in appropriate AAP group (n = 6,038) and 16.91% in inappropriate AAP group (n = 6,038) over 6-month follow-up in the matched cohort. The robust Cox proportional hazards models revealed increased risk of all-cause mortality (hazard ratio [HR] 1.13 [95% confidence interval {CI}: 1.01-1.28)] for patients who used inappropriate compared to appropriate AAPs. Risk of death was also higher for risperidone compared to quetiapine (HR: 1.20 [95% CI: 1.03-1.40]) in sensitivity analysis. However, there was a significant relationship between pneumonia and death in all analyses. The impact of inappropriate AAP use on mortality was not significant when pneumonia was modeled as a mediator.Conclusions: Inappropriate AAP use is associated with a higher risk of all-cause-mortality in older patients with PD which is mainly mediated by pneumonia. Therefore, inappropriate AAP use should be avoided to improve quality of care in PD. [ABSTRACT FROM AUTHOR]

Background: Although the adverse cognitive effects of anticholinergic medications in the elderly are well-documented, little is known regarding the cognitive impact of anticholinergics among nursing home residents with depression.Objective: This study examined the risk of mild-to-moderate cognitive impairment due to anticholinergic burden among elderly nursing home residents with depression.Methods: A population-based nested case-control study was conducted using Minimum Data Set (MDS)-linked Medicare data where the base cohort included patients ≥ 65 years with depression who had intact cognition (MDS Cognition score of 0 or 1) and no dementia. Cases were identified as those who had mild-to-moderate cognition (MDS Cognition score of 2-4). Each case was matched on age and sex to one control using incidence density sampling. The study evaluated cumulative anticholinergic burden (defined as score of 3 or more) within 30, 60 and 90 days preceding the event date based on the Anticholinergic Drug Scale (ADS). Conditional logistic regression model stratified on matched case-control sets was performed to evalaute cognitive impairment due to cumulative anticholinergic burden after controlling for other risk factors.Results: The study sample included 3707 cases with mild-to-moderate cognition and 3707 matched controls with intact cognition. Bivariate analysis showed significant association between cumulative anticholinergic exposure and cognitive impairment (Odds Ratio [OR], 1.15; 95% Confidence Interval [CI],1.04-1.30); after controlling for potential risk factors, cumulative anticholinergic exposure 30 days preceding the event was no longer associated with cognitive impairment, (aOR, 1.07; 95% CI, 0.95-1.21). However, the odds of cognitive impairment increased with cumulative anticholinergic exposure 60 days (aOR 1.16; 1.04-1.30) and 90 days (aOR 1.28; 1.14-1.44) before the event date.Conclusion: Cumulative anticholinergic use for prolonged exposure periods was associated with modestly increased risk of cognitive impairment in elderly residents with depression who had intact cognition. The findings suggest the need to be cautious when prescribing multiple anticholinergic drugs in residents, including those with intact cognition. [ABSTRACT FROM AUTHOR]

Objective: To examine patient and provider characteristics associated with the use of pediatric psychotropic polypharmacy.Methods: A retrospective study was conducted on children with psychiatric disorder diagnosis and treatment using the 2013-2015 claims data from a Pediatric Medicaid Managed Care Plan. Psychotropic polypharmacy was defined as the receipt of ≥2 psychotropic medications from different drug classes concurrently for ≥60 days. Stratified logistic regression analyses based on the number of prescribers involved in the treatment, i.e. single prescriber (SP) and multiple prescribers (MP) were conducted to determine the risk factors associated with multiclass psychotropic polypharmacy. The Fairlie decomposition method was used to test the difference in receipt of psychotropic polypharmacy between patients with and without a psychiatrist visit.Results: A total of 24,147 children and adolescents met the inclusion criteria. The prevalence of psychotropic polypharmacy was 20.09%. In addition to patients' demographics, diagnoses, number of comorbid psychiatric disorders (MP only), and the number of prescribers involved in the treatment (MP only), patients with a psychiatrist involved in the treatment had 5.3 times and 3.6 times higher odds of receiving psychotropic polypharmacy in SP and MP groups respectively (SP: OR = 5.32; 95% CI 4.62-6.14 & MP: OR = 3.57; 95% CI 3.20-3.99). Only a quarter of the prescribing practice variation between psychiatrists and PCPs was explained by the observed need factors.Conclusions: Pediatric psychotropic polypharmacy may be necessary and justified as it is mainly prescribed by the best-trained providers. [ABSTRACT FROM AUTHOR]

Background: Atypical antipsychotics are used as monotherapy or as augmentation therapy for management of late-life depression. However, little is known about utilization pattern of atypical antipsychotics in depression in the elderly.Objective: The objective of this study was to examine the prescribing practices and predictors of atypical antipsychotics and augmentation therapy in elderly outpatient visits with depression.Methods: This retrospective cross-sectional study used the National Ambulatory Medical Care Survey (NAMCS) and outpatient department component of the National Hospital Ambulatory Medical Care Survey (NHAMCS) data from 2010 and 2011. The study included elderly (age ≥ 65years) outpatient visits with depression. Descriptive weighted analysis was performed to determine the prescribing practices of atypical antipsychotics and multivariable logistic regression analyses were performed to determine the factors associated with the prescription of atypical antipsychotics and augmentation therapy in outpatient visits.Results: According to the national surveys, there were about 22 million outpatent visits for depression during the study period; atypical antipsychotics were prescribed in 3.53% (95% CI, 2.02-5.04) of the visits. Among depression patients who were using antidepressants, 4.86% (95% CI, 3.07-6.04) used as an augmentation therapy. Multivariable regression analysis revealed that Hispanics (odds ratio [OR] = 0.33; 95% CI, 0.12-0.90) were associated with decreased likelihood of antipsychotic prescription, whereas personality disorder and obsessive compulsive disorder (OR = 10.23; 95% CI, 2.80-37.40) were associated with increased likelihood of prescribing antipsychotics. For augmentation therapy, Hispanics (OR = 0.06; 95% CI, 0.02-0.24) and primary physicians (OR = 0.24; 95% CI, 0.09-0.69) were associated with decreased likelihood; and obsessive compulsive disorder and personality disorder (OR = 7.56; 95% CI, 1.75-32.69) were associated with increased likelihood of antipsychotic prescription.Conclusion: Less than 4% of the elderly visits with depression were prescribed atypical antipsychotics. Both clinical and demographic factors contribute to antipsychotic prescribing in elderly patients with depression. [ABSTRACT FROM AUTHOR]

Background: Limited research exists regarding Medication Regimen Complexity Index (MRCI) and its utility in identifying patients at risk for hospital readmission.Objective: This study evaluates the association between discharge MRCI and 30-day rehospitalization in patients with heart failure (HF) after discharge.Methods: The study involved a retrospective, cohort study at a large tertiary teaching facility from the University HealthSystem Consortium. The consortium database was used to identify HF patients hospitalized from January 2011 to December 2013. A 30-day readmission was defined as being readmitted to the same hospital within 30 days of discharge with a principal discharge diagnosis of HF. Index hospitalizations was defined as the first hospitalization, and readmission was the subsequent hospitalization for HF. A pilot analysis was conducted to compare manual MRCI collection tool and a computerized scoring MRCI system. Multivariable logistic regression was used to examine the association of computerized MRCI (≥15) and 30-day rehospitalization after controlling for other variables.Results: A total of 1,452 patients were included in the study with 81 patients (5.9%) readmitted within 30 days of discharge. The manual and computerized MRCIs were correlated with an R of 0.74 and R2 of 0.55. The multivariate logistic regression analysis found computerized MRCI ≥15 (OR: 1.62; 95% CI: 1.01-2.59) was associated with 30-day rehospitalization after controlling for other factors. Patients prescribed angiotensin-converting-enzyme inhibitors or angiotensin receptor blockers, were less likely (OR: 0.54; CI: 0.33-0.89) to be readmitted 30 days after discharge, and patients with coronary artery disease were more likely (OR: 1.76; CI: 1.03-3.00) to be readmitted 30 days after discharge.Conclusions: The computerized MRCI score was moderately correlated with manual MRCI score. A significant association was found between computerized MRCI and 30-day HF readmission. Such predictive tools may allow pharmacists to prioritize patient care and optimize patient outcomes through medication therapy management. [ABSTRACT FROM AUTHOR]

Background: Proton pump inhibitors (PPIs) can lead to several adverse effects among the elderly, particularly when used inappropriately or in contrast to evidence suggested protocols.Objective: The aim of this study was to examine the prevalence and predictors of non-evidence based PPI use in elderly nursing home residents.Methods: A cross-sectional study was conducted using data from the 2004 National Nursing Home Survey (NNHS). The study sample included nursing home residents 65 years and older. Descriptive statistics were used to examine the prevalence of non-evidence based PPI use. Multivariable logistic regression was used to evaluate the patient and facility-level factors associated with non-evidence based PPI use among the elderly nursing home residents.Results: A total of 355,600 elderly nursing home residents received at least one PPI for an overall prevalence of 26.99%. Among those elderly receiving PPIs, 48.59% of the use was not evidence based. Multivariable logistic regression revealed that residents with osteoporosis (Odds Ratio (OR): 0.55, 95% CI: 0.45-0.68), SSRI users (OR: 0.81, 95% CI: 0.68-0.97) and those residing in micropolitan area (OR: 0.79, 95% CI: 0.63-0.98) were negatively associated with prescription of PPIs without an indication. Patients with chronic cough (OR: 2.10, 95% CI: 1.12-3.96) and Medicare insurance (OR: 1.23, 95% CI: 1.01-1.50) were positively associated with prescription of PPIs without an indication.Conclusions: The current study found that almost half of the elderly nursing home residents used PPIs for non-evidence based indications. Given the safety concerns and high non-evidence based use of PPIs in nursing homes, there is an urgent need to optimize PPI use in the elderly. [ABSTRACT FROM AUTHOR]

Background: The disability inherent to Parkinson's disease and dementia would suggest poor health-related quality of life for patients with these neurodegenerative conditions; however, the extent of disability from a nationally representative data has not been previously available.Objectives: This study examined factors associated with the health-related quality of life in patients with Parkinson's disease and dementia using nationally representative samples.Methods: The study used data from 2002 to 2011 Medical Expenditure Panel Survey (MEPS), a nationally representative survey of households in the United States. The quality of life of patients was captured based on Physical Component Summary (PCS), Mental Component Summary (MCS), Activities of Daily Living (ADL) and Instrumental Activities of Daily Living (IADL). Multivariate regression models were used to compare PCS, MCS, ADL and IADL across the two neurodegenerative conditions after controlling for various sociodemographic and clinical characteristics.Results: The weighted study population included 0.80 million (95% Confidence Interval, CI: 0.75-0.85) patients; those with Parkinson's disease accounted for 40.23% and remaining 59.77% were diagnosed with dementia. Mean age of the study population was 74.32 years (Standard Deviation, SD = 11.36). Most of the Parkinson's patients were male (57.70%), whereas most of the dementia patients were females (58.10%). The unadjusted mean PCS was 33.66 and 35.31 in Parkinson's and dementia patients, respectively (P < 0.01). Patients with Parkinson's disease were less likely to seek help for IADL than neurodegenerative dementia (Odds Ratio, OR = 0.68, P = 0.02). Various other individual, biological and environmental factors were also associated with quality of life in patients with Parkinson's disease and neurodegenerative dementia.Conclusions: This study found that patients with Parkinson's disease had lower PCS and were less likely to seek help for IADL when compared to the patients with neurodegenerative dementia. Knowledge of these factors can be helpful in improving quality of life of patients with neurodegenerative diseases. [ABSTRACT FROM AUTHOR]

Objective: To examine the risk of dementia with anticholinergic use among elderly nursing home residents with depression.Design: Population-based nested case-control study.Setting: Population-based study involving 2007-2010 Minimum Data Set-linked Medicare data from all 50 states.Participants: Medicare beneficiaries aged 65 years and older, diagnosed with depression, and no history of dementia as of 2007 (baseline period). Cases were identified as patients with incident dementia following the baseline period. For each case, four age- and sex-matched control subjects were selected using incidence density sampling.Measurements: Anticholinergic exposure was defined using Anticholinergic Drug Scale. Prescription of clinically significant anticholinergic medications (levels 2 and 3) 30 days preceding the event date formed the primary exposure. The primary outcome was dementia diagnosis, between January 1, 2008, and December 31, 2010. A conditional logistic regression model stratified on matched case-control sets was performed to assess dementia risk, after controlling for other risk factors.Results: The study sample included 28,388 cases diagnosed with dementia and 113,352 matched control subjects. After adjusting for other risk factors, clinically significant anticholinergic use was associated with significant risk of dementia (OR: 1.26; 95% CI: 1.22-1.29) compared with non-use. The findings remained consistent across levels of anticholinergic potency (level 2, OR: 1.37, 95% CI: 1.31-1.44; level 3, OR: 1.15, 95% CI: 1.10-1.19).Conclusion: Use of clinically significant anticholinergic medications was associated with a 26% increase in risk of dementia among elderly nursing home residents with depression. With increasing safety concerns, there is a significant need to optimize anticholinergic use, especially for those who are at risk for dementia. [ABSTRACT FROM AUTHOR]

• This study found that patients with Multiple Sclerosis (MS) have lower physical and mental Health-Related Quality of Life (HRQoL) than their non-MS counterparts. • MS patients were more likely to seek help for help for Activities of Daily Living (ADL) and Instrumental Activities of Daily Living (IADL) than non-MS adults. Multiple sclerosis (MS) is a progressive autoimmune disease of the central nervous system. Both the physical and mental burden of MS affect patients' health-related quality of life (HRQoL). However, there is limited research at the national level evaluating the humanistic burden among MS patients. This study evaluated the HRQoL and functional limitations among MS patients using ten years of national survey data. Guided by the conceptual framework of the Wilson and Cleary model, this study compared HRQoL between adults diagnosed with MS (Clinical Classification Code= "080″) and non-MS adults using the 2006–2015 Medical Expenditure Panel Survey (MEPS) data. The humanistic burden included HRQoL and functional limitations. The HRQoL was evaluated using physical component summary (PCS) and mental component summary (MCS) based on the Short Form Health Survey (SF-12). The study applied the multivariable Generalized Linear Models (GLM) to estimate the marginal differences in PCS and MCS based on the SF-12. In addition, seeking help for activities of daily living (ADL) and instrumental activities of daily living (IADL) were modeled with multivariable logistic regression. According to the MEPS, the estimated annual prevalence of MS was 0.52 million (95% Confidence Interval [CI]: 0.42–0.60). MS patients were mainly female (71.90%), middle aged (50–64 years, 40.21%), non-Hispanic whites (78.29%), and enrolled in private insurance plans (68.93%). The average PCS scores in MS and non-MS groups were 35.70 and 49.48, respectively. The average MCS scores were 45.58 and 51.25 for MS and non-MS groups, respectively. In addition, 18.26% of MS patients sought help for ADL, and 27.08% sought help for IADL. After adjusting for individual, biological, and environmental characteristics, the multivariable GLM with Poisson distribution indicated that the marginal difference of PCS score was 11.10 (95% CI: 9.50–12.61) units lower, and the MCS score was 4.89 (95% CI: 3.44–6.30) units lower among MS patients. In addition, MS patients were 17.32 (95% CI: 11.61–25.84) and 14.43 (95% CI: 10.09–20.65) times more likely to request assistance for ADL and IADL, respectively. MS was associated with lower physical and mental HRQoL than their non-MS counterparts and MS patients were more likely to request help for ADL and IADL. More work is needed to evaluate the effect of treatment strategies on improving the HRQoL and functional limitations in MS. [ABSTRACT FROM AUTHOR]

Objective: To examine the prevalence and predictors of potentially inappropriate anticholinergic medication use in older adults with dementia.Design: A cross-sectional study.Setting: United States, 2009-2010.Participants: Medical Expenditure Panel Survey household component participants aged 65 years or older identified as having dementia and using potentially inappropriate anticholinergic medication.Main Outcome Measures: Prevalence and predictors of potentially inappropriate anticholinergic medication use as per the updated 2012 American Geriatrics Society Beers criteria.Results: A total of 3.78 million older adult patients (95% confidence interval [CI] 3.17 million to 4.38 million) were identified as having dementia, for an overall prevalence of 4.81%. Of those patients, an estimated 1.02 million (95% CI 0.70 million to 1.30 million) were reported to use potentially inappropriate anticholinergic medications, for an overall prevalence of 26.95% (95% CI 20.10% to 33.79%). The most frequently prescribed drugs were oxybutynin, solifenacin, paroxetine, tolterodine, promethazine, and cyclobenzaprine. Multivariable logistic analysis revealed that those patients with the need characteristics of self-reported anxiety, mood disorders, and "fair/poor" general health status had increased odds of potentially inappropriate anticholinergic use, while patients with the predisposing characteristic of being aged 75-84 years had decreased odds of potentially inappropriate anticholinergic use.Conclusion: More than one in four older adults with dementia were found to use potentially inappropriate anticholinergics. Given the adverse cognitive effects of these medications, there is a strong need to monitor and optimize their use in older adult patients with dementia. [ABSTRACT FROM AUTHOR]

Objectives: To examine the association between the use of anticholinergic drugs and the health-related quality of life (HRQoL) among community-dwelling older adults with dementia. Methods: This was a retrospective, longitudinal, cohort study of older adults aged 65 years and above diagnosed with dementia using Medical Expenditure Panel Survey data. Anticholinergic drug exposure was measured using the Anticholinergic Drug Scale. The HRQoL measures of interest were Physical Component Score (PCS) and Mental Component Score (MCS). Two separate unweighted multiple linear regression analyses were performed to determine the association of anticholinergic drugs with PCS and MCS, while adjusting for other factors and baseline HRQoL measures. Results: The study included 112 patients with dementia; 15.18% of whom used anticholinergic drugs. The majority of the patients were between the ages of 65 and 79 years (53%), women (57%), and had poor or low family income (65%). After controlling for other factors and baseline HRQoL, anticholinergic drug use was associated with 7.48 unit reductions in PCS (P <0.01), whereas no association was found between anticholinergic drug use and MCS. Baseline HRQoL measures were found to be significant in both models. Conclusion: Anticholinergic drugs are associated with reduced PCS of HRQoL in older adults with dementia. The study findings suggest the need for carefully monitoring the health status of elderly patients when prescribing anticholinergic agents in this vulnerable population. [ABSTRACT FROM AUTHOR]

Since the introduction of oral disease-modifying agents (DMA) in 2010, the treatment options for multiple sclerosis (MS) have changed significantly. There is limited information regarding the factors associated with switching to oral DMA among prevalent injectable DMA users. This study evaluated the factors associated with switching to oral DMAs among prevalent injectable DMA users with MS. A retrospective observational cohort study using the TriNetX electronic medical records (EMR) data was conducted among patients with MS. The study included prevalent injectable DMA users with at least two injectable DMA (interferon beta-1a, interferon beta-1b, peginterferon beta-1a, or glatiramer acetate) prescription records within 6 months between September 2010 and May 2018. The second injectable DMA prescription date was considered as the index date. Switching was defined as any oral DMA prescription record (fingolimod, dimethyl fumarate, or teriflunomide) within 12 months after the index date. Patients with any infusion DMA prescription after the first injectable DMA prescription, and those less than 18 years of age were excluded from the study. The Andersen Behavioral Model was used as the conceptual framework to identify predisposing, enabling, and need factors measured during the 1-year baseline period before the index date. A multivariable logistic regression model was used to examine the predisposing (age, sex, race, and ethnicity), enabling (time-period), and need factors (comorbidities, MS symptoms, MS-related medication, and healthcare utilization) associated with switching from injectable to oral DMAs. Among 2,943 prevalent injectable users included in this study, 8.09% (n=238) patients switched to oral DMAs. Patients who switched to oral DMAs were primarily younger adults aged 18-44 years (64.29%), females (82.77%), had sensory and visual symptoms, and had corticosteroid utilization during the one-year look-back period compared to non-switchers. Results from multivariable logistic regression model revealed that middle-aged adults (45-64 years, adjusted odds ratio [aOR]: 0.43, 95% Confidence Interval [CI]: 0.32-0.58), old adults (≥65 years, aOR: 0.30, 95% CI: 0.13-0.66) and men (aOR: 0.67, 95% CI: 0.47-0.96) were associated with decreased odds of switching to oral DMAs. Presence of MS-related sensory symptoms (aOR: 1.52, 95% CI: 1.07-2.16), visual symptoms (aOR: 1.59, 95% CI: 1.10-2.31), and corticosteroids usage (aOR: 1.44, 95% CI: 1.04-1.98) were associated with increased odds of switching to oral DMAs. The study found that about one in twelve prevalent injectable DMA users switched to oral DMA. Both demographic and clinical factors were associated with switching to oral DMAs. Further research is needed to evaluate the outcomes of switching to inform treatment decisions for MS management. [ABSTRACT FROM AUTHOR]

Abstract: Background: The nonlinear Blinder-Oaxaca (BO) decomposition method is gaining popularity in health services research because of its ability to explain disparity issues. The present study demonstrates the use of this method for categorical variables by addressing antiobesity medication use disparity. Objective: To examine racial/ethnic disparity in antiobesity medication use and to quantify the observed factor contribution behind the disparity using the nonlinear BO decomposition. Methods: Medical Expenditure Panel Survey data, 2002-2007, were used in this retrospective cross-sectional study. Adults with body mass index (BMI) >30, or BMI ≥27 and comorbidities such as hypertension, cardiovascular diseases, diabetes, or hyperlipidemia were included in the cohort (N=65,886,625). Multivariable logistic regression was performed to examine racial/ethnic disparity in antiobesity medication use controlling for predisposing, enabling, and need factors. The nonlinear BO decomposition was used to identify the contribution of each predisposing, enabling, and need factors in explaining the racial/ethnic disparity and to estimate the residual unexplained disparity. Results: Non-Hispanic Blacks were 46% (odds ratio [OR]: 0.54; 95% confidence interval [CI]: 0.35-0.83) less likely to use antiobesity drugs compared with non-Hispanic Whites, whereas no difference was observed between Hispanics and non-Hispanic Whites. A 0.22 percentage point of disparity existed between non-Hispanic Whites and Blacks. The nonlinear BO decomposition estimated a decomposition coefficient of −0.0013 indicating that the observed disparity would have been 58% higher (−0.0013/0.0022) if non-Hispanic Blacks had similar observed characteristics as non-Hispanic Whites. Age, gender, marital status, region, and BMI were significant factors in the decomposition model; only marital status explained the racial/ethnic disparity among all observed characteristics. Conclusions: The study revealed that differences in the predisposing, enabling, and need characteristics (except marital status) did not successfully explain the racial/ethnic disparity in antiobesity medication use. Further studies examining racial/ethnic differences in individual beliefs, behavioral patterns, and provider prescription patterns are vital to understand these disparities. [Copyright &y& Elsevier]

Abstract: Background: Diabetes and hypertension are independent risk factors for dementia, and hypertension may increase this risk in patients with diabetes. It is unclear whether antihypertensive drugs are associated with risk of dementia in these patients. Methods: A retrospective study using a national cohort of beneficiaries of the Department of Veterans Affairs who have diabetes examined incidence of dementia over a 2-year follow-up period. Multivariate Cox proportional hazards regression model was used to estimate the unique effects of comorbid hypertension and antihypertensive medications on risk of dementia, after adjusting for several potential confounders. Results: In all, 377,838 patients were studied (mean age: 75.53 ± 6.07 years). After adjustments were made for sociodemographic factors, duration of diabetes, comorbidity, and comedications, hypertension was associated with increased risk of developing dementia (hazard ratio [HR] = 1.08; 95% confidence interval [CI] = 1.03, 1.14). Antihypertensive medications decreased risk, ranging from 24% for angiotensin receptor blockers (ARBs) to 4% for β-blockers. In a stratified analysis of patients without hypertension, angiotensin-converting enzyme inhibitors (HR = 0.81; 95% CI = 0.69, 0.94) and ARBs (HR = 0.55; 95% CI = 0.34, 0.88) continued to show protective effects. Conclusions: Comorbid hypertension was associated with increased risk of dementia, whereas antihypertensive medications, especially angiotensin-converting enzyme inhibitors and ARBs, were associated with reduced risk, even among patients without hypertension. Consequently, these agents may have potential therapeutic roles in delaying the onset of dementia in patients with diabetes. [Copyright &y& Elsevier]

Abstract: Background: Atypical antipsychotic agents are extensively prescribed in the elderly to treat various behavioral and psychiatric disorders. Past literature has documented an increased risk of falls and factures with the use of risperidone and olanzapine compared with nonuse. However, none of the studies assessed the comparative safety profiles of atypical agents with respect to falls and fractures. Objective: The goal of this study was to evaluate the risk of falls and fractures associated with the use of risperidone, olanzapine, and quetiapine in community-dwelling adults aged ≥50 years. Methods: The study involved a propensity score–adjusted approach in new users of risperidone, olanzapine, or quetiapine anytime between July 1, 2000, and June 30, 2008, using data from the IMS LifeLink Health Plan Claims database. Patients were followed up until a hospitalization/emergency department visit for fall/fracture or the end of the study period, whichever occurred earlier. The Cox proportional hazards regression model was used to evaluate the comparative risk of falls/fractures. The covariates in the final model included propensity scores and their interaction terms. Results: There were 12,145 new users of atypical agents in the study population (5083 risperidone, 4377 olanzapine, and 2685 quetiapine). A total of 417 cases of falls/fractures with at least 1 hospitalization/ emergency department visit after the use of the antipsychotic agents were identified. The number of falls for risperidone, olanzapine, and quetiapine were 179 (3.56%), 123 (2.84%), and 115 (4.34%), respectively. After adjusting for propensity scores, the Cox proportional hazards model showed that there was no statistically significant difference with use of risperidone (hazard ratio = 1.10 [95% CI, 0.86–1.39]) or quetiapine (hazard ratio = 1.12 [95% CI, 0.86–1.46]) compared with olanzapine (reference group) in the risk of falls or fractures. Conclusions: The study found no significant difference across the individual atypical agents in the risk of falls/fractures in community-dwelling older adults. Future studies are required to evaluate the overall safety profiles of the antipsychotic agents in this population. [Copyright &y& Elsevier]

Abstract: Background: Heart failure is a major and growing public health problem in United States. There is a substantial evidence about efficacy of angiotensin-converting enzyme inhibitors (ACEIs) in heart failure (HF); however, there is no conclusive evidence on the relative effectiveness of individual ACEIs. Objective: To evaluate the effect of individual ACEIs on mortality using multiple-propensity score analysis in a large real-world population. Methods: The study was a retrospective analysis of a national cohort of patients with HF identified from the Department of Veterans Affairs. A multiple-propensity score analysis was used to balance 47 baseline patient characteristics between different nontissue ACEIs. The effect of different ACEIs on time to death was assessed using a propensity score-weighted, multivariable Cox proportional hazard model. Results: The study included 139,994 patients with 69.50% (97,293) on lisinopril, 21.79% (30,503) on fosinopril, 8.41% (11,775) on captopril, and 0.30% (423) on enalapril. Propensity scores balanced nearly all differences between different ACEI groups. Fosinopril (hazard ratio [HR]=0.739, 95% confidence interval [CI]: 0.686-0.797) and lisinopril (HR=0.818, 95% CI: 0.766-0.874) were significantly associated with reduced mortality as compared with captopril. Similar mortality was observed with enalapril (HR=0.944, 95% CI: 0.675-1.320) as compared with captopril. Conclusions: In patients with HF, fosinopril and lisinopril were associated with lower mortality as compared with captopril. However, the results of this observational study should be interpreted with caution, and need to be replicated and confirmed in studies for which HF severity data are available. [Copyright &y& Elsevier]

Objectives: To determine the prevalence and predictors of human papillomavirus (HPV) vaccination in adolescent girls who were recommended to receive the vaccine by their health care providers. Design: Cross-sectional study. Setting: United States in 2007-08. Participants: Parents or guardians most knowledgeable about health and health care of adolescent girls aged 12 to 17 years participating in the 2007 National Survey of Children's Health (NSCH). Intervention: NCSH was a population-based telephone survey using a complex probability sampling design. Main outcome measures: Prevalence of HPV vaccination in adolescent girls who were recommended to receive the HPV vaccine and predisposing, enabling, and need factors associated with HPV vaccination. Results: Of 12.38 million adolescent girls aged 12 to 17 years, 3.69 million (29.76%) were recommended to receive the HPV vaccine by their health care provider. The majority who received the HPV vaccine recommendation were 13 to 17 years of age (83%), were white (71%), and had one or more preventive visits (94%). Among those for whom the HPV vaccine was recommended, 48.75% (95% CI 45.37-52.13) received the vaccine. Multivariate logistic regression analysis of those who were recommended revealed that enabling and predisposing factors were significantly associated with the HPV vaccination. Children living at 101% to 200% of the Federal Poverty Level (odds ratio 0.54 [95% CI 0.30-0.98]) and children in households with two or more adults (0.51 [0.33-0.80]) were negatively associated with HPV vaccination, whereas children with any preventive medical care visit(s) (2.28 11.36-3.84]) in the previous year were positively associated with HPV vaccination. Conclusion: Nearly one-half of adolescent girls received the HPV vaccine among those who were recommended by their health care provider. The study finding emphasizes the importance of predisposing and enabling factors for HPV vaccination. Policy and education efforts can focus on these factors to improve HPV vaccination rates. [ABSTRACT FROM AUTHOR]

Abstract: Background: Anticholinergic medications, although frequently used in elderly populations, are associated with cognitive impairment and constitute significant concern for patients with dementia. Objective: The purpose of our study was to examine patterns and predictors of prescribing anticholinergic agents for elderly outpatients with dementia. Methods: We combined data from the 2006–2007 National Ambulatory Medical Care Survey and the outpatient department component of National Hospital Ambulatory Medical Care Survey to analyze patient visits by elderly persons (aged ≥65 years) with dementia. Anticholinergic drugs were identified using the Anticholinergic Drug Scale, which classifies anticholinergic drugs into four levels (0–3) in increasing order of anticholinergic activity. Descriptive analysis using sampling weights was used to evaluate patterns of anticholinergic drug prescription, especially prescribing of medications with clinically significant anticholinergic activity (ie, levels 2 or 3). Multiple logistic regression was used in the conceptual framework of the Andersen Behavioral Model to examine the predisposing, enabling, and need factors associated with prescribing of medications with clinically significant anticholinergic activity. Results: According to the national surveys there were a total of 6.8 million (95% CI, 5.27–8.44 million; 0.32%) ambulatory care visits for dementia. Approximately 43% (42.86%; 95% CI, 35.24–50.48) of these visits involved prescribing at least one anticholinergic drug; and 10.07% of visits involved prescribing levels 2 or 3 anticholinergic medications. The predisposing factor, age (75–84 years; odds ratio [OR] = 0.25; 95% CI, 0.07–0.87), and the need factors, acetylcholinesterase inhibitor use (OR = 0.25; 95% CI, 0.07–0.86) and comorbid mood disorders (OR = 0.12; 95% CI, 0.02–0.73), were associated with decreased likelihood of prescribing medications with clinically significant anticholinergic activity. The need factor total number of medications prescribed (OR = 1.45, 95% CI, 1.20–1.75) increased the likelihood of these prescriptions being administered. Conclusions: One in 10 outpatient visits by elderly persons with dementia involved prescribing medications with clinically significant anticholinergic activity. Given their adverse cognitive effects, there is a strong need to optimize anticholinergic drug prescribing in vulnerable elderly outpatients with dementia. [Copyright &y& Elsevier]

Abstract: Background: Late-life depression is a common psychiatric disorder associated with increased morbidity and mortality. Depression is often under-detected and undertreated in elderly nursing home residents. Objectives: The aim of this study was to examine the prevalence of antidepressant drug use and to identify the factors associated with its use among elderly nursing home residents. Methods: The study involved the analysis of a nationally representative sample of prescription and resident files from the 2004 National Nursing Home Survey (NNHS). The study sample included all elderly nursing home residents ≥65 years of age. The analysis focused on prescribing from any antidepressant class, including selective serotonin reuptake inhibitors (SSRIs), tricyclic antidepressants (TCAs), serotonin modulators, serotonin-norepinephrine reuptake inhibitors (SNRIs), monoamine oxidase inhibitors (MAOIs), and others. Descriptive weighted analysis was performed to examine antidepressant use prevalence patterns in elderly nursing home residents. Multiple logistic regression analysis within the conceptual framework of Anderson''s behavioral model was used to examine the predisposing, enabling, and need characteristics associated with antidepressant use. Results: According to the 2004 NNHS, overall prevalence of antidepressant use among elderly nursing home residents was 46.22% (95% CI, 45.16–47.27). Most antidepressant users were ≥85 years of age (49.7%), female (75.7%), non-Hispanic (96.4%), and white (91.1%). The most prescribed class of antidepressants was SSRIs (31.09%; 95% CI, 30.12–32.07), followed by serotonin modulators (4.65%; 95% CI, 4.22–5.09), SNRIs (2.78%; 95% CI, 2.45–3.12), TCAs (2.34%; 95% CI, 2.03–2.65), and MAOIs (0.01%; 95% CI, 0.00–0.03). Citalopram (12.92%; 95% CI, 12.21–13.63) was the most prescribed individual antidepressant, followed by mirtazapine (10.19%; 95% CI, 9.55–10.84). Among the predisposing characteristics, age, race, and marital status were significantly associated with antidepressant use. The odds of receiving an antidepressant were lower for those aged ≥85 years and those who were unmarried elderly residents, when compared with their counterparts; whites were more likely to receive an antidepressant than nonwhites. Enabling factors such as Medicaid and bed capacity significantly predicted antidepressant use. Having Medicaid was positively associated with antidepressant prescription, whereas an increase in the total number of beds decreased the probability of an antidepressant prescription. Among need characteristics, the likelihood of antidepressant prescription use decreased with increased dependence in decision-making ability and out-of-bed mobility. The presence of depressed mood indicators and a history of falls/fractures increased the likelihood of antidepressant prescription use. The odds of receiving an antidepressant increased with diagnosis of depression but decreased with diagnosis of anxiety. Conclusion: Nearly half of elderly nursing home residents received antidepressants. In addition to need factors, predisposing and enabling factors played an important role in influencing the use of antidepressants in elderly nursing home residents. [Copyright &y& Elsevier]

Abstract: Background: Antipsychotic agents can lead to severe cardiovascular adverse events due to multiple mechanisms involving electrophysiologic and metabolic effects. Few epidemiologic studies have evaluated the risk of serious cardiovascular-related events in typical and atypical antipsychotic users. Objective: The purpose of this study was to compare the risk of serious cardiac events in older adults taking typical antipsychotics with those taking atypical antipsychotics. Methods: Prescription and medical information were derived from the IMS LifeLink Health Plan Claims database. The study involved a retrospective cohort of older adults (≥50 years) taking atypical or typical antipsychotics from July 1, 2000, to December 31, 2007. The primary outcome measure was hospitalization or emergency room visit due to serious cardiac events, including thromboembolism, myocardial infarction, cardiac arrest, and ventricular arrhythmias within 1 year after the index date. The 2 groups were matched on a propensity score to minimize the baseline differences between the groups. Survival analysis was conducted on the matched cohort to assess the risk of serious cardiovascular events in typical versus atypical users. Results: A total of 5580 patients were selected in each antipsychotic users group after propensity score matching. Serious cardiac events were found in 666 (11.9 %) atypical antipsychotic users and 698 (12.4%) typical antipsychotic users. Survival analysis revealed that typical antipsychotic users were at increased risk of serious cardiovascular events compared with atypical antipsychotic users (hazard ratio = 1.21; 95% CI, 1.04–1.40) after controlling for other factors. Conclusions: Moderate increases in risk of serious cardiac events are associated with older adults using typical antipsychotic agents compared with atypical users. Health care professionals should carefully evaluate the benefit/risk ratio of antipsychotic agents before prescribing these agents to a vulnerable population. [Copyright &y& Elsevier]

The article presents a retrospective cohort study which compares the risk of cerebrovascular side effects with second-generation antipsychotic users and those using first-generation antipsychotics in adults. The study gathered a total of 11,160 older adults using second-generation antipsychotics and 5,580 users of first-generation antipsychotics. Researchers found that using second-generation antipsychotics were not linked to an increased risk of cerebrovascular side effects.

Objective: To examine the nature and extent of unmet prescription medication need (UPMN) in children and its predictors using the 2003 National Survey of Children's Health (NSCH). Design: Retrospective cross-sectional survey. Selling: United States in 2003-2004. Participants: Parents or guardians who knew most about child's (<18 years of age) health and health care and reported about their children's prescription medication use. Intervention: NSCH-a population-based telephone survey--based on complex probability sampling design. Main outcome measures: Nature and extent of UPMN in children and predictors of UPMN for any reason and as a result of cost, health plan problems, and lack of insurance within the conceptual framework of the Andersen behavioral model. Results: According to NSCH, 0.54 million (95% CI 0.46-0.62) or 1.23% (1.05-1.41%) of children experienced UPMN. The highest prevalence of UPMN was seen among blacks (2.3%), families with income less than 200% of federal poverty level (2.4%), and those having good, fair, or poor perceived health status (3.2%). A high prevalence of UPMN was also found in children with gained (5.3%), lost (3.7%), or no insurance (6.4%). Among children with UPMN, 35.39% (28.56-42.23%) did not receive medications because of cost, 26.51% (20.28-32.74%) because of health plan problems, and 40.73% (33.21-48.24%) because of lack of insurance. Multivariate logistic regression analysis revealed that predisposing (race), enabling (poverty and insurance), and need (perceived health status and depression) factors were significantly associated with UPMN for any reason. Factors significantly associated with UPMN due to cost included enabling (insurance) and need (attention deficit hyperactivity disorder and asthma) factors. The predictors of UPMN resulting from health plan problems included predisposing (race) and enabling (insurance) factors, whereas UPMN caused by lack of insurance was only associated with an enabling factor (age). Conclusion: More than 0.5 million children in the United States experienced UPMN, mainly as a result of cost, health plan problems, or lack of insurance. The study findings suggest that a need exists for addressing racial disparities and continuity of coverage issues in children to improve access to needed prescription medications. [ABSTRACT FROM AUTHOR]

Abstract: 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. [Copyright &y& Elsevier]