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Background: Antimicrobial resistance is driven by inappropriate antimicrobial prescribing. The National Antimicrobial Prescribing Survey (NAPS) is an Australian-developed auditing platform to assist in the assessments of antimicrobial quality by antimicrobial stewardship programmes using consensus-based definitions. The NAPS has demonstrated to be transferable to other countries. Its adaptation to Portugal could improve knowledge about the quality of antimicrobial prescribing in the country., Objectives: To translate, culturally adapt, and validate the Australian Hospital NAPS appropriateness assessment definitions of antimicrobial prescribing for Portugal., Methods: International recommendations on translation and adaptation of instruments were followed. Two panels of experts participated in the process, using Zoom® for discussions and interviews, and Google Forms® for assessing vignettes. A native English-speaking person proficient in Portuguese conducted the back-translation. SPSS v.28 and Excel® were used for validity calculation., Results: The Portuguese version was well accepted, its implementation being perceived as desirable and feasible by the experts. Validation process showed a Fleiss' κ score of 0.483 (95% CI, 0.415-0.551, P < 0.005) for appropriateness, and an average agreement with the Australian NAPS team of 0.8 and 0.9, respectively, for appropriateness and reasons for inappropriateness., Conclusions: The Portuguese version of the Australian Hospital NAPS appropriateness assessment definitions of antimicrobial prescribing, the first to be translated from English, was deemed non-inferior to the original, was well accepted, considered to be desirable and feasible, and could inspire other countries, particularly other Portuguese-speaking countries, to adapt and validate them in their own contexts, reinforcing the possibility of transferring NAPS use beyond Australia., (© The Author(s) 2024. Published by Oxford University Press on behalf of British Society for Antimicrobial Chemotherapy.)

Objectives: Dentists manage a variety of oral infections in clinical practice. Inappropriate antimicrobial prescribing by dentists occurs frequently and antimicrobial stewardship strategies should include dentistry. The aim of this retrospective analysis of the Australian Hospital National Antimicrobial Prescribing Survey (Hospital NAPS) dataset, was to describe the types of oral and dental indications where antimicrobials were prescribed, and assess the guideline compliance and appropriateness of the antimicrobials in Australian hospitals., Methods: Data from the Hospital NAPS was extracted for oral and dental indications from 2013 to 2022. The types of oral and dental indications presented, and the corresponding antimicrobials prescribed were assessed for compliance according to national prescribing guidelines, and appropriateness according to the NAPS structured algorithm., Results: A total of 8,001 prescriptions for 7,477 patients were identified, from 433 hospitals. Antifungal, antibiotic and antiviral agents accounted for 84.5 %, 15.4 % and 0.03 % of prescriptions respectively. A greater proportion of antibiotics were prescribed in regional and rural areas compared to antifungals. The prescriptions assessed as compliant were 80.0 % and 44.7 % of antifungals and antibiotics respectively. Prescriptions assessed as appropriate were 84.4 % of antifungals, and 65.3 % of antibiotic prescriptions., Conclusions: A wide variety of antimicrobials were used with moderate levels of compliance and appropriateness. Future interventions should include targeted education, utilisation of prescribing guidelines, and tools to diagnose and manage oral and dental conditions. Consideration can be given to adjustment of the Hospital NAPS tool to cater for oral conditions and include the provision of dental treatment in the management of these infections., Clinical Significance: A wide variety of oral and dental conditions are presented in Australian hospital settings, managed by a range of antibiotics and antifungals, with moderate levels of compliance to guidelines and appropriateness. Antimicrobial stewardship strategies should target and support dentistry in hospital settings., Competing Interests: Declaration of competing interest The authors have no conflicts of interest., (Copyright © 2024. Published by Elsevier Ltd.)

Problem: Prescribing by Endorsed Midwives has existed in Australia for more than ten years. Significant barriers exist in the bureaucracy surrounding prescribing and state and territory legislation which further constrain midwives capacity to prescribe required medications., Background: Current evidence indicates Endorsed Midwives improve timely access to medications and can experience both enablers and barriers to prescribing., Aim: To explore Endorsed Midwives' lived experiences of medication prescribing, including which medications are being prescribed, how this affects the women in their care, midwives' practice, and perspectives on the future of midwifery prescribing., Methods: A descriptive qualitative approach was used. Data collection occurred through semi-structured interviews (n=10) of Endorsed Midwives from varied Australian practice contexts and locations. Data analysis followed Reflexive Thematic Analysis., Findings: Four themes were developed: Medication prescription as essential healthcare; Prescribing optimises midwifery practice; External structures can both promote and inhibit the capacity to prescribe; The future of prescribing., Discussion: Endorsed Midwife prescribing has the potential to positively impact women's maternity care and enable midwives to fulfil their scope of practice. However, limitations to prescribing need to be addressed to capitalise on these benefits., Conclusion: Significant reform of health service policy, state and territory legislation and further development of the Pharmaceutical Benefits Scheme are required to fully embrace and capitalise on the full scope of Endorsed Midwives in the Australian Healthcare system., (Copyright © 2024 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Context: The increase and global dissemination of antibiotic resistance limit the use of antibiotics to prevent and treat infections. Implementing antibiotic stewardship programs guided by local data on prescription profiles is a useful strategy to reduce the burden of antibiotic resistance. The aim was to determine the prevalence of antibiotic use and guideline compliance at Luang Prabang provincial hospital, Lao PDR., Methods: A point prevalence survey of antibiotics was conducted among hospitalized patients admitted to Luang Prabang hospital (204 beds) in Lao PDR on May 25, 2023. All patients presenting at 8:00 AM were eligible. Sociodemographic data, indications for antibiotic use, and antibiotic prescriptions were collected from medical records using a paper-based questionnaire and entered into an electronic platform following WHO methodology. The prevalence of antibiotic use was determined., Results: Out of the 102 patients included, 60(58.8%) were undergoing antibiotic treatment, of which 33(55.0%) received combination therapy, and 7(10.5%) had two indications for antibiotic use. The highest prevalence was in the surgical ward (14/15, 93%) followed by general paediatrics (18/27, 67%). Out of the 100 antibiotic prescriptions, 47(47%) were for community-acquired infections, 26(26%) for surgical prophylaxis, 13(13%) for hospital-acquired infections and 5(5%) for medical prophylaxis. Twenty(20%) antibiotics were prescribed for obstetrics and gynaecology prophylaxis, 17(17%) for intra-abdominal infections, and 10(10.0%) for pneumonia treatment as well as bone, and joint infections. The main antibiotics prescribed were ceftriaxone 36(34.6%), metronidazole 18(17.3%), ampicillin 8(7.7%), and gentamicin 8(7.7%). Only 2(3%) samples were sent to the laboratory, one of which showed a positive culture for Escherichia coli Extended Spectrum β-Lactamase. According to the WHO Access Watch and Reserve classification, 55(52.9%) molecules belonged to the Access category, 47(49.1%) to the Watch category, and none to the Reserve category. Only 14.9% of antibiotic prescriptions were fully compliant with current guidelines., Conclusion: This study indicated a significant prevalence of antibiotic use and a very low compliance with guidelines at Luang Prabang provincial hospital, Lao PDR. This highlights an urgent need for comprehensive strategies at all levels to optimize antibiotic use in hospitals, emphasizing diagnostic improvements, and continued research to address the factors driving this excessive antibiotic usage and improve adherence to guidelines., (© 2024. The Author(s).)

Introduction: Irrational prescribing and dispensing of oral dosage forms of medicines to paediatric patients are major public health issues, especially in low-income and middle-income countries. Many challenges affect the rational use of oral dosage forms of medicines in children; these include a lack of dosage forms appropriate for the age and a lack of dose flexibility in dosage forms., Objectives: To assess the rational prescribing and dispensing practices of oral dosage forms to children at dispensaries of the University of Gondar Comprehensive and Specialised Hospital (UoGCSH)., Method: A retrospective design for prescribing indicators and a cross-sectional study design to assess rational dispensing were used at the outpatient dispensary units of UoGCSH. A total of 931 oral dosage forms to assess prescribing indicators and 400 for dispensing indicators were used. The data were analysed using the Statistical Package for Social Sciences (SPSS V.26.0, IBM Corporation). Descriptive statistics were used to analyse indicators, and the χ 2 test was used to compare indicators between dispensaries., Result: Out of a total of 931 oral dosage forms for 700 prescriptions, 56.3% were solid oral dosage forms. An average number of oral dosage forms per child was 1.33±0.62. Only 150 (16.13%) (95% CI: 14% to 18.4%) were adequate for the weight of the child. The percentage of oral dosage forms not suitable for the age was 7.1% (66), (95% CI: 5.6% to 8.8%), and about 0.8% (95% CI: 0% to 1.8%) were adequately labelled. Drugs that needed manipulation before administering a single unit were 81 (39.7%), 95% CI: 33.7% to 47.1%., Conclusion: The proportion of the prescribed medications that were adequate for the weight of the child was low, although the majority of prescriptions' weights were not recorded. Oral dosage forms not suitable for children were prescribed. The proportion of medications that needed manipulation before being administered as a single unit was high., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

The Finnish web-based Meds75+ database supports rational, safe and appropriate prescribing to older adults in primary care. This article describes the content and updating process of Meds75+ and demonstrates its applicability in everyday clinical practice. Meds75+ contains a classification (A-D) and recommendation texts for 450-500 drug substances when used in the treatment of older adults aged 75 years or older. The content of Meds75+ is continually updated. Each assessment of a drug substance begins with a structured collection of available information and research evidence. After that, an interdisciplinary expert panel discusses the classification and recommendation using a consensus method. A rolling 3-year updating cycle guarantees that all drug substances are reviewed regularly. Most drug substances are classified as class A (41%) (suitable, e.g. bisoprolol) or as class C (37%) (suitable with specific precautions, e.g. ibuprofen). One-fifth (20%) of the substances are in class D (avoid use, e.g. diazepam). Most commonly, older adults have purchased substances affecting the alimentary tract and metabolism (17%), the nervous system (16%) and the cardiovascular system (15%). In Finland, the proportion of older adults using class D substances (37%) has not changed between the years 2019 and 2022. Meds75+ has potential to support safer and more effective use of medications for older adults, since it offers up-to-date information on drug substances for healthcare professionals., (© 2024. The Author(s).)

Background: General practitioners (GPs) make numerous care decisions throughout their workdays. Extended periods of decision making can result in decision fatigue, a gradual shift toward decisions that are less cognitively effortful. This study examines whether observed patterns in GPs' prescribing decisions are consistent with the decision fatigue phenomenon. We hypothesized that the likelihood of prescribing frequently overprescribed medications (antibiotics, benzodiazepines, opioids; less effortful to prescribe) will increase and the likelihood of prescribing frequently underprescribed medications (statins, osteoporosis medications; more effortful to prescribe) will decrease over the workday., Methods: This study used nationally representative primary care data on GP-patient encounters from the Bettering the Evaluation and Care of Health program from Australia. The association between prescribing decisions and order of patient encounters over a GP's workday was assessed with generalized linear mixed models accounting for clustering and adjusting for patient, provider, and encounter characteristics., Results: Among 262,456 encounters recorded by 2,909 GPs, the odds of prescribing antibiotics significantly increased by 8.7% with 15 additional patient encounters (odds ratio [OR] = 1.087; confidence interval [CI] = 1.059-1.116). The odds of prescribing decreased significantly with 15 additional patient encounters by 6.3% for benzodiazepines (OR = 0.937; CI = 0.893-0.983), 21.9% for statins (OR = 0.791; CI = 0.753-0.831), and 25.0% for osteoporosis medications (OR = 0.750; CI = 0.690-0.814). No significant effects were observed for opioids. All findings were replicated in confirmatory analyses except the effect of benzodiazepines., Conclusions: GPs were increasingly likely to prescribe antibiotics and were less likely to prescribe statins and osteoporosis medications as the workday wore on, which was consistent with decision fatigue. There was no convincing evidence of decision fatigue effects in the prescribing of opioids or benzodiazepines. These findings establish decision fatigue as a promising target for optimizing prescribing behavior., Highlights: We found that as general practitioners progress through their workday, they become more likely to prescribe antibiotics that are reportedly overprescribed and less likely to prescribe statins and osteoporosis medications that are reportedly underprescribed.This change in decision making over time is consistent with the decision fatigue phenomenon. Decision fatigue occurs when we make many decisions without taking a rest break. As we make those decisions, we become gradually more likely to make decisions that are less difficult.The findings of this study show that decision fatigue is a possible target for improving guideline-compliant prescribing of pharmacologic medications., Competing Interests: The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Financial support for this study was provided by a Small Research Grant from the Royal Society of Edinburgh (grant ID: 2156). The funding agreement ensured that authors’ independence in designing the study, interpreting the data, writing, and publishing the report. The BEACH project itself was funded through arm’s length research agreements with the following organizations: Abbott Australasia; AbbVie; AstraZeneca (Australia); Australian Government Department of Health; Australian Government Department of Veterans’ Affairs; Aventis Pharma; Bayer Australia; bioCSL (Australia); GlaxoSmithKline Australia; Janssen-Cilag; Merck, Sharp and Dohme (Australia); National Prescribing Service; Novartis Pharmaceuticals Australia; Pfizer Australia; Roche Product; Sanofi-Aventis Australia; Wyeth Australia.

Study Objective: The aim of this quality improvement (QI) project was to assess postoperative narcotic use after pediatric gynecologic surgeries and establish standard postoperative opioid dosing. Through standard dosing, we hoped to decrease variability in postoperative opioid prescriptions and decrease excess opioid doses in the community., Methods: This quality improvement project was approved by the Children's Minnesota institutional review board. Counseling on postoperative pain management was provided pre- and postoperatively. At the 2-week postoperative visit, patients were asked about the number of opioid doses used and pain control satisfaction. Baseline data were collected for 6 months, with surgeons prescribing the number of opioid doses on the basis of their personal preference. After reviewing the prescribing practices and number of doses used, standard opioid doses were established, and data collection was repeated., Results: Complete data were recorded for 30 cases before implementation of standard doses and for 29 cases after implementation. Standardized opioid dosing resulted in a 30% decrease in total opioid doses in circulation (252 to 176 doses; P = .014) and a 15% reduction in excess doses in circulation (162 to 137 doses). Forty-three percent of patients did not use any opioid doses. There was no significant difference (P = .8818) in patient pain control satisfaction rating., Conclusion: Standard opioid dose prescribing is feasible for common pediatric gynecologic surgeries without affecting patient pain control satisfaction. Opioid dose standardization may decrease opioid circulation within the community. Approximately 2 of every 5 patients used 0 opioid doses, which suggests that a further reduction in the standard dose prescriptions is possible., Competing Interests: Conflicts of Interest The authors of this paper have nothing to disclose., (Copyright © 2024. Published by Elsevier Inc.)

Objective: To identify the frequency and types of prescription errors, assess adherence to WHO prescribing indicators, and highlight the gaps in current prescribing practices of Junior dental practitioners in a tertiary care hospital in Karachi, Pakistan., Methods: This cross-sectional study was conducted from January 2021 to March 2021. The study included the prescriptions by house surgeons and junior postgraduate medical trainees for walk-in patients visiting the dental outpatient department. A total of 466 prescriptions were evaluated for WHO core drug prescribing indicators. The prescription error parameters were prepared by studying the WHO practical manual on guide to good prescribing and previous studies. Prescription errors, including errors of omission related to the physician and the patients, along with errors of omission related to the drug, were also noted. The statistical analysis was performed with SPSS version 25. Descriptive analysis was performed for qualitative variables in the study., Results: The average number of drugs per encounter was found to be 3.378 drugs per prescription. The percentage of encounters with antibiotics was 96.99%. Strikingly, only 16.95% of the drugs were prescribed by generic names and 23.55% of drugs belonged to the essential drug list. The majority lacked valuable information related to the prescriber, patient, and drugs. Such as contact details 419 (89.9%), date 261 (56%), medical license number 466 (100%), diagnosis 409 (87.8%), age and address of patient 453 (97.2%), form and route of drug 14 (3%), missing drug strength 69 (14.8%), missing frequency 126 (27%) and duration of treatment 72 (15.4%). Moreover, the wrong drug dosage was prescribed by 89 (19%) prescribers followed by the wrong drug in 52 (11.1%), wrong strength in 43 (9.2%) and wrong form in 9 (1.9%). Out of 1575 medicines prescribed in 466 prescriptions, 426 (27.04%) drug interactions were found and 299 (64%) had illegible handwriting., Conclusion: The study revealed that the prescription writing practices among junior dental practitioners are below optimum standards. The average number of drugs per encounter was high, with a significant percentage of encounters involving antibiotics. However, a low percentage of drugs were prescribed by generic name and from the essential drug list. Numerous prescription errors, both omissions and commissions, were identified, highlighting the need for improved training and adherence to WHO guidelines on good prescribing practices. Implementing targeted educational programs and stricter regulatory measures could enhance the quality of prescriptions and overall patient safety., (© 2024. The Author(s).)

Background: Literature on advanced practice providers (APPs) prescribing chemotherapy independently, without physician cosignature, is limited., Objectives: This project assessed safety and provider satisfaction for an existing independent APP chemotherapy prescribing privilege at a National Cancer Institute-designated comprehensive cancer center., Methods: Rate of Reporting to Improve Safety and Quality events associated with APPs with independent chemotherapy prescribing privileges was compared to that of physicians during a three-year period. Satisfaction of APPs with independent chemotherapy prescribing privileges was evaluated., Findings: The odds of a reported event were higher for physicians than for APPs. APP survey responses were positive for readiness, confidence, and satisfaction with independent chemotherapy prescribing privilege.

There has been a rapid increase in remote patient consultations, including remote prescribing - partly in response to the coronavirus disease 2019 (COVID-19) pandemic, but also as part of the move towards a 'digital first' NHS. There are various benefits associated with remote prescribing, such as convenience for patients and judicious use of healthcare resources. However, it is also associated with several risks, for example the use of inappropriate medicines or doses if the prescriber does not have full access to the patient's records. This article considers some of the benefits and challenges of remote prescribing, and discusses the main principles of effective practice in relation to patient safety, informed consent and documentation., Competing Interests: None declared, (© 2024 RCN Publishing Company Ltd. All rights reserved. Not to be copied, transmitted or recorded in any way, in whole or part, without prior permission of the publishers.)

Introduction: Post-appendectomy opioid prescription practices may vary widely across and within health care systems. Although guidelines encourage conservative opioid prescribing and prescribing of non-opioid pain medications, the variation of prescribing practices and the probability of opioid refill remain unknown in the U.S. Military Health System., Materials and Methods: This retrospective observational cohort study evaluated medical data of 11,713 patients who received an appendectomy in the Military Health System between January 2016 and June 2021. Linear-mixed and generalized linear-mixed models evaluated the relationships between patient-, care-, and system-level factors and the two primary outcomes; the morphine equivalent dose (MED) at hospital discharge; and the probability of 30-day opioid prescription refill. Sensitivity analyses repeated the generalized linear-mixed model predicting the probability of opioid (re)fill after an appendectomy, but with inclusion of the full sample, including patients who had not received a discharge opioid prescription (e.g., 0 mg MED)., Results: Discharge MED was twice the recommended guidance and was not associated with opioid refill. Higher discharge MED was associated with opioid/non-opioid combination prescription (+38 mg) relative to opioid-only, lack of non-opioid prescribing at discharge (+6 mg), care received before a Defense Health Agency opioid safety policy was released (+61 mg), documented nicotine dependence (+8 mg), and pre-appendectomy opioid prescription (+5 mg) (all P < .01). Opioid refill was more likely for patients with complicated appendicitis (OR = 1.34; P < .01); patients assigned female (OR = 1.25, P < .01); those with a documented mental health diagnosis (OR = 1.32, P = .03), an antidepressant prescription (OR = 1.84, P < .001), or both (OR = 1.54, P < .001); and patients with documented nicotine dependence (OR = 1.53, P < .001). Opioid refill was less likely for patients who received care after the Defense Health Agency policy was released (OR = 0.71, P < .001), were opioid naive (OR = 0.54, P < .001), or were Asian or Pacific Islander (relative to white patients, OR = 0.68, P = .04). Results from the sensitivity analyses were similar to the main analysis, aside from two exceptions. The probability of refill no longer differed by race and ethnicity or mental health condition only., Conclusions: Individual prescriber practices shifted with new guidelines, but potentially unwarranted variation in opioid prescribing dose remained. Future studies may benefit from evaluating patients' experiences with pain management, satisfaction, and patient-centered education after appendectomy within the context of opioid prescribing practices, amount of medications used, and refill probability. Such could pave a way for standardized patient-centered procedures that both decrease unwarranted prescribing pattern variability and optimize pain management regimens., (Published by Oxford University Press on behalf of the Association of Military Surgeons of the United States 2023. This work is written by (a) US Government employee(s) and is in the public domain in the US.)

This article describes historical and political reasons for-and devastating consequences of-US opioid prescribing policy since the 1990s, which has restricted opioid prescribing for pain less than for treating opioid use disorder (OUD) treatment. This article considers merits and drawbacks of a new diagnostic category and proposes a regulatory and clinical framework for prescribing long-term opioid therapy for pain and for prescribing opioids to treat OUD., (Copyright 2024 American Medical Association. All Rights Reserved.)

Insufficient labeling information regarding the appropriate age for prescribing drugs to the pediatric population is challenging. This study aimed to analyze the off-label prescription of age-related drugs for pediatric patients using claims data from South Korea and to assess the consistency of the approved age in South Korea, the United States, Europe, and Japan. In 2020, 1004 unique drugs were prescribed to the pediatric population in South Korea. We found that 641 drugs (63.8%, p < 0.0001) were related to off-label prescriptions for age-related use at least once, and the total number of off-label prescriptions was 2,236,669 (62.2%, p < 0.0001). Chlorpheniramine (28%) was the most frequently prescribed drug for pediatric patients with an age-related off-label, followed by budesonide (9%) and epinephrine (9%). The degree of agreement in the approved age range for 641 off-label drugs across countries was assessed using the overall kappa coefficient. We observed slight agreement in labeling across all countries (κ: 0.16, 95% confidence interval [CI]: 0.14-0.18). The highest degree of agreement was observed between the United States and Europe (0.41, 0.37-0.45) due to pediatric-population-specific legislation. South Korea showed the lowest degree of agreement with the United States and Europe (0.10, 0.06-0.14). The United States, Europe, and Japan showed fair agreement (0.23, 0.21-0.26). However, the degree of agreement between South Korea, the United States, and Japan (0.09, 0.06-0.11) and South Korea, Europe, and Japan (0.08, 0.05-0.10) was low. This study highlights the need for South Korean regulatory agencies to consider introducing pediatric legislation to prescribe evidence-based drugs for safe and effective use., (© 2024 The Author(s). Clinical and Translational Science published by Wiley Periodicals LLC on behalf of American Society for Clinical Pharmacology and Therapeutics.)

Non-steroidal anti-inflammatory drugs (NSAIDs) are commonly prescribed to alleviate pain and inflammation in conditions like arthritis, migraines, and post-operative recovery. Their mechanism involves inhibiting prostaglandins that contribute to inflammation. NSAIDs are categorized based on their structure, selectivity for COX-1 and COX-2 enzymes, and plasma half-life. They are effective in treating osteoarthritis, spondyloarthritis, and rheumatoid arthritis but might carry an elevated risk of adverse events. Despite their effectiveness, NSAIDs have limitations and risks that warrant cautious consideration. Extensive research has investigated their side effects, and this review aims to examine the current limitations of oral NSAID therapy, including safety profiles, specific scenarios where their use may not be appropriate, and gaps in knowledge. By critically evaluating these aspects, healthcare practitioners can make informed decisions about prescribing NSAIDs, optimizing patient outcomes while minimizing potential risks. This narrative review summarizes existing knowledge and underscores the importance of risk-benefit assessments in NSAID prescribing. Ultimately, the goal is to enhance the rational use of NSAIDs, maximizing benefits while mitigating adverse effects., (Copyright © 2023 Société française de rhumatologie. Published by Elsevier Masson SAS. All rights reserved.)

Introduction: Antimicrobial resistance is a global issue, and implementation of antimicrobial stewardship programs in outpatient settings is crucial. Japan has also focused on outpatient oral antimicrobial stewardship programs and difficulties in standardizing prescriptions have led to overprescription in primary emergency medical centers. There is a lack of research investigating the antibiotic prescription status of pediatric primary emergency medical centers and the benchmark prescription rates in pediatric outpatient settings., Methods: We conducted a multi-center, cross-sectional study of seven pediatric primary emergency medical centers located in five prefectures of Japan. We retrospectively extracted data from health claims or directly obtained them from charts at each institution and evaluated trends in the antibiotic prescription rate based on the AWaRe classification between April 2016 and December 2019., Results: Our study included 383,525 encounters, with the most common infectious disease diagnosis being acute upper respiratory tract infection in 93,449 cases (24.4 %). The antibiotic prescription rate during the study period was 7.4 %, representing a decrease of 46 %, from 10.2 % in 2016 to 5.5 % in 2019. The percentage of prescriptions in the Access group increased at all institutions; however, it exceeded 60 % in only three facilities in 2019. The percentage of third-generation cephalosporins varied among facilities, ranging from 1.7 % to 59.4 %, as of 2019., Conclusions: For pediatric primary emergency medical centers where antimicrobial stewardship programs are implemented, we suggest 5 % as a reasonable benchmark level for the antibiotic prescription rate. Prescribing the antibiotics in the Access groups less frequently remains a domestic challenge in Japan., Competing Interests: Declaration of competing interest The authors declare that they have no conflicts of interest to disclose. Informed Consent and Ethical Approval. We obtained opt-out consent from the patients' parents. This study was approved by the institutional ethics committees of Kobe Children's Hospital (Approval Number 2021–61)., (Copyright © 2024 Japanese Society of Chemotherapy, Japanese Association for Infectious Diseases, and Japanese Society for Infection Prevention and Control. Published by Elsevier Ltd. All rights reserved.)

Objectives: To evaluate whether providing family physicians with feedback on their antibiotic prescribing compared with that of their peers reduces antibiotic prescriptions. To also identify effects on antibiotic prescribing from case-mix adjusted feedback reports and messages emphasising antibiotic associated harms., Design: Pragmatic, factorial randomised controlled trial., Setting: Primary care physicians in Ontario, Canada PARTICIPANTS: All primary care physicians were randomly assigned a group if they were eligible and actively prescribing antibiotics to patients 65 years or older. Physicians were excluded if had already volunteered to receive antibiotic prescribing feedback from another agency, or had opted out of the trial., Intervention: A letter was mailed in January 2022 to physicians with peer comparison antibiotic prescribing feedback compared with the control group who did not receive a letter (4:1 allocation). The intervention group was further randomised in a 2x2 factorial trial to evaluate case-mix adjusted versus unadjusted comparators, and emphasis, or not, on harms of antibiotics., Main Outcome Measures: Antibiotic prescribing rate per 1000 patient visits for patients 65 years or older six months after intervention. Analysis was in the modified intention-to-treat population using Poisson regression., Results: 5046 physicians were included and analysed: 1005 in control group and 4041 in intervention group (1016 case-mix adjusted data and harms messaging, 1006 with case-mix adjusted data and no harms messaging, 1006 unadjusted data and harms messaging, and 1013 unadjusted data and no harms messaging). At six months, mean antibiotic prescribing rate was 59.4 (standard deviation 42.0) in the control group and 56.0 (39.2) in the intervention group (relative rate 0.95 (95% confidence interval 0.94 to 0.96). Unnecessary antibiotic prescribing (0.89 (0.86 to 0.92)), prolonged duration prescriptions defined as more than seven days (0.85 (0.83 to 0.87)), and broad spectrum prescribing (0.94 (0.92 to 0.95)) were also significantly lower in the intervention group compared with the control group. Results were consistent at 12 months post intervention. No significant effect was seen for including emphasis on harms messaging. A small increase in antibiotic prescribing with case-mix adjusted reports was noted (1.01 (1.00 to 1.03))., Conclusions: Peer comparison audit and feedback letters significantly reduced overall antibiotic prescribing with no benefit of case-mix adjustment or harms messaging. Antibiotic prescribing audit and feedback is a scalable and effective intervention and should be a routine quality improvement initiative in primary care., Trial Registration: ClinicalTrials.gov NCT04594200., Competing Interests: Competing interests: All authors have completed the ICMJE uniform disclosure form at www.icmje.org/disclosure-of-interest/ and declare: funding by the Canadian Institute for Health Research; JAL reports financial compensation for expert testimony by the Ontario Hospital Association, Ontario Ministry of the Attorney General, Seneca College and Choosing Wisely Canada. TG reports financial compensation from the Ontario Ministry of Health, Ontario College of Pharmacists, the Canadian Agency for Drugs and Technologies in Health, and Indigenous Services Canada. All other authors declare no support from any organisation for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work., (© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objectives: Variability in opioid-prescribing practices after common pediatric surgical procedures at our institution prompted the development of opioid-prescribing guidelines that provided suggested dose limitations for narcotics. The aims of this study were to improve opioid prescription practices through implementation of the developed guidelines and to assess compliance and identify barriers preventing guideline utilization., Methods: We conducted a single-center cohort study of all children who underwent the most common outpatient general surgery procedures at our institution from August 1, 2018, to February 1, 2020. We created guidelines designed to limit opioid prescription doses based on data obtained from standardized postoperative telephone interviews. Three 6-month periods were evaluated: before guideline implementation, after guideline initiation, and after addressing barriers to guideline compliance. Targeted interventions to increase compliance included modification of electronic medical record defaults and provider educations. Differences in opioid weight-based doses prescribed, filled, and taken, as well as protocol adherence between the 3 timeframes were evaluated., Results: A total of 1033 children underwent an outpatient procedure during the 1.5-year time frame. Phone call response rate was 72.22%. There was a significant sustained decrease in opioid doses prescribed ( P < 0.0001), prescriptions filled ( P = 0.009), and opioid doses taken ( P = 0.001) after implementation, without subsequent increase in reported pain on postoperative phone call ( P = 0.96). Protocol compliance significantly improved (62.39% versus 83.98%, P < 0.0001) after obstacles were addressed., Conclusions: Implementation of a protocol limiting opioid prescribing after frequently performed pediatric general surgery procedures reduced opioids prescribed and taken postoperatively. Interventions that addressed barriers to application led to increased protocol compliance and sustained decreases in opioids prescribed and taken without a deleterious effect on pain control., Competing Interests: The authors disclose no conflict of interest., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Pharmacists and physicians play key roles in antimicrobial stewardship. This commentary on a case describes these health professionals' need to collaborate to optimize therapeutic use of antimicrobials in clinical settings. Prescription preauthorization is one antimicrobial stewardship strategy that can meet with some physicians' frustration and generate conflict between pharmacists and prescribing physicians, particularly when pharmacists make alternative treatment recommendations. This commentary considers interprofessional tension concerning prescription preauthorization and suggests strategies for navigating such conflict., (Copyright 2024 American Medical Association. All Rights Reserved.)

Background: Many institutions have developed operation-specific guidelines for opioid prescribing. These guidelines rarely incorporate in-hospital opioid consumption, which is highly correlated with consumption. We compare outcomes of several patient-centered approaches to prescribing that are derived from in-hospital consumption, including several experimental, rule-based prescribing guidelines and our current institutional guideline., Study Design: We performed a retrospective, cohort study of all adults undergoing surgery at a single-academic medical center. Several rule-based guidelines, derived from in-hospital consumption (quantity of opioids consumed within 24 hours of discharge), were used to specify the theoretical quantity of opioid prescribed on discharge. The efficacy of the experimental guidelines was compared with 3 references: an approximation of our institution's tailored prescribing guideline; prescribing all patients the typical quantity of opioids consumed for patients undergoing the same operation; and a representative rule-based, tiered framework. For each scenario, we calculated the penalized residual sum of squares (reflecting the composite deviation from actual patient consumption, with 15% penalty for overprescribing) and the proportion of opioids consumed relative to prescribed., Results: A total of 1,048 patients met inclusion criteria. Mean (SD) and median (interquartile range [IQR]) quantity of opioids consumed within 24 hours of discharge were 11.2 (26.9) morphine milligram equivalents and 0 (0 to 15) morphine milligram equivalents. Median (IQR) postdischarge consumption was 16 (0 to 150) morphine milligram equivalents. Our institutional guideline and the previously validated rule-based guideline outperform alternate approaches, with median (IQR) differences in prescribed vs consumed opioids of 0 (-60 to 27.25) and 37.5 (-37.5 to 37.5), respectively, corresponding to penalized residual sum of squares of 39,817,602 and 38,336,895, respectively., Conclusions: Rather than relying on fixed quantities for defined operations, rule-based guidelines offer a simple yet effective method for tailoring opioid prescribing to in-hospital consumption., (Copyright © 2024 by the American College of Surgeons. Published by Wolters Kluwer Health, Inc. All rights reserved.)

Background: To examine whether the "Effectiveness of Guideline for Dissemination and Education in psychiatric treatment (EGIUDE)" project affects the rate of prescriptions of hypnotic medication and the type of hypnotic medications prescribed among psychiatrists, for schizophrenia and major depressive disorder in Japan., Methods: The EGUIDE project is a nationwide prospective study of evidence-based clinical guidelines for schizophrenia and major depressive disorder in Japan. From 2016 to 2021, clinical and prescribing data from patients discharged from hospitals participating in the EGUIDE project were used to examine hypnotic medication prescriptions The prescribing rate of hypnotics and the prescribing rate of each type of hypnotic (benzodiazepine receptor agonist, nonbenzodiazepine receptor agonist, melatonin receptor agonist, and orexin receptor antagonist) were compared among patients who had been prescribed medication by psychiatrists participating in the EGUIDE project and patients who had been prescribed medication by nonparticipating psychiatrists. Multivariate logistic regression analysis was performed to examine the effect of the EGUIDE project on the prescription of hypnotic medications., Results: A total of 12,161 patients with schizophrenia and 6,167 patients with major depressive disorder were included. Psychiatrists participating in the EGUIDE project significantly reduced the rate of prescribing hypnotic medication and benzodiazepine receptor agonists for both schizophrenia (P < 0.001) and major depressive disorder (P < 0.001) patients., Conclusion: This is the first study to investigate the educational effects of guidelines for the treatment of psychiatric disorders on psychiatrists in terms of prescribing hypnotic medications to patients. The EGUIDE project may play an important role in reducing hypnotic medication prescription rates, particularly with respect to benzodiazepine receptor agonists. The results suggest that the EGUIDE project may result in improved therapeutic behavior., (© 2024. The Author(s).)

Purpose: Recommendations to improve therapeutics are proposals made by pharmacists during the prescription review process to address suboptimal use of medicines. Recommendations are generated daily as text documents but are rarely reused beyond their primary use to alert prescribers and caregivers. If recommendation data were easier to summarize, they could be used retrospectively to improve safeguards for better prescribing. The objective of this work was to train a deep learning algorithm for automated recommendation classification to valorize the large amount of recommendation data., Methods: The study was conducted in a French university hospital, at which recommendation data were collected throughout 2017. Data from the first 6 months of 2017 were labeled by 2 pharmacists who assigned recommendations to 1 of the 29 possible classes of the French Society of Clinical Pharmacy classification. A deep neural network classifier was trained to predict the class of recommendations., Results: In total, 27,699 labeled recommendations from the first half of 2017 were used to train and evaluate a classifier. The prediction accuracy calculated on a validation dataset was 78.0%. We also predicted classes for unlabeled recommendations collected during the second half of 2017. Of the 4,460 predictions reviewed, 67 required correction. When these additional labeled data were concatenated with the original dataset and the neural network was retrained, accuracy reached 81.0%., Conclusion: To facilitate analysis of recommendations, we have implemented an automated classification system using deep learning that achieves respectable performance. This tool can help to retrospectively highlight the clinical significance of daily medication reviews performed by hospital clinical pharmacists., (© American Society of Health-System Pharmacists 2024. All rights reserved. For commercial re-use, please contact reprints@oup.com for reprints and translation rights for reprints. All other permissions can be obtained through our RightsLink service via the Permissions link on the article page on our site—for further information please contact journals.permissions@oup.com.)

Competing Interests: Conflicts of interest The authors declare no conflicts of interest.

Objective: Prescriptions for atypical antipsychotics in children and adolescents are increasing globally. However, a precise understanding of the clinical variables and evidence that prescribers consider before using these agents is lacking. While empirical literature on the long-term safety and efficacy of these medications is available, the literature concerning their use in these younger age groups is relatively sparse. In this study, we examined the current prescribing patterns of medical professionals employed by a public health service in Australia., Methods: A survey examining their current practice when prescribing atypical antipsychotics to children and adolescents was completed by 103 physicians. Questions were asked about commonly prescribed atypical antipsychotics, indications, dose ranges, target symptoms, duration of treatment, and the evidence base(s) used when making treatment decisions., Results: Physicians prescribed atypical antipsychotics for a wide range of indications in this age group, with the most common agents being risperidone, quetiapine, and olanzapine. Adverse effects were reported as the main reason for treatment discontinuation. More than half of the respondents indicated that the most common source of guidance/evidence they referred to when initiating prescriptions were peers or expert opinion., Conclusions: Children and adolescents were prescribed a number of atypical antipsychotics for a variety of indications, with variable perceived confidence and a relatively heavy reliance on "own or peer experience" as opposed to good quality evidence. Challenges exist for both prescribers and policymakers, and further "head-to-head" studies are needed in this age group to ensure that a balance is maintained between therapeutic benefit and safety., Competing Interests: F.D.Z. was the recipient of an unrestricted award donated by the American Psychiatric Association, the American Psychiatric Institute for Research and Education (APIRE), and AstraZeneca (Young Minds in Psychiatry Award). He has also received research support from the German Federal Ministry for Economics and Technology, the European Commission, the Princess Margaret Hospital Foundation, the Telethon Perth Children’s Hospital Research Fund (TPCHRF), the Telethon Kids Institute in Perth, the German Society for Social Pediatrics and Adolescent Medicine, the Paul and Ursula Klein Foundation, the Dr August Scheidel Foundation, the Interdisciplinary Center for Clinical Research (IZKF) fund of the University Hospital of RWTH Aachen University, and a travel stipend donated by the Glaxo SmithKline Foundation. He is the recipient of an unrestricted educational grant, travel support, and speaker honoraria from Shire Pharmaceuticals, Germany. In addition, he has received support from the Raine Foundation for Medical Research (Raine Visiting Professorship) and editorial fees from Co-Action Publishing (Sweden). The remaining authors declare no conflicts of interest., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Importance: Although the intention of the 2016 US Centers for Disease Control and Prevention (CDC) Guideline for Prescribing Opioids for Chronic Pain was not to limit pain treatment for patients with sickle cell disease (SCD), clinicians and patients have recognized the possibility that the guideline may have altered outcomes for this population. However, the outcomes of the 2016 guideline for this patient population are unknown., Objective: To examine changes in opioid prescribing patterns and health outcomes among patients with SCD before and after the release of the 2016 CDC guideline., Design, Setting, and Participants: This retrospective cohort study conducted interrupted time series analysis of claims data from the Merative MarketScan Commercial Database from January 1, 2011, to December 31, 2019. In this population-based study in the US, individuals with SCD who were at least 1 year of age, had no cancer diagnosis, and had pharmacy coverage for the month of measurement were included. The data were analyzed from January 2021 to November 2023., Exposure: The CDC Guideline for Prescribing Opioids for Chronic Pain released in March 2016., Main Outcomes and Measures: The main variables measured in this study included the practice of opioid prescribing among patients with SCD (ie, rate of opioid prescriptions dispensed, mean number of days supplied, mean total morphine milligram equivalents [MME] per patient, and mean daily MME per opioid prescription) and pain-related health outcomes (rates of emergency department visits related to vaso-occlusive crises [VOC] and hospitalizations related to VOC)., Results: The cohort included 14 979 patients with SCD (mean [SD] age, 25.9 [16.9] years; 8520 [56.9%] female). Compared with the preguideline trends, the following changes were observed after the guideline was released: significant decreases in the coefficient for change in slope of the opioid dispensing rate (-0.29 [95% CI, -0.39 to -0.20] prescriptions per 100 person-month; P < .001), the number of days supplied per prescription (-0.05 [95% CI, -0.06 to -0.04] days per prescription-month; P < .001), and opioid dosage (-141.0 [95% CI, -219.5 to -62.5] MME per person-month; P = .001; -10.1 [95% CI, -14.6 to -5.6] MME/prescription-month; P < .001). Conversely, a significant increase in VOC-related hospitalizations occurred after the guideline release (0.16 [95% CI, 0.07-0.25] hospitalizations per 100 person-month; P = .001). These changes were observed to a greater extent among adult patients, but pediatric patients experienced similar changes in several measures, even though the guideline focused exclusively on adult patients., Conclusions and Relevance: This retrospective cohort study showed that the 2016 CDC guideline may have had unintended negative outcomes on the patient population living with SCD.

Purpose: It is unclear how the evidence from clinical trials best translates into complex clinical settings. The aim of this quality improvement (QI) project was to change prescribing practice for rapid tranquillization in inpatient mental health care services examining the effectiveness of the Plan-Do-Study-Act (PDSA) method., Methods: A prospective QI project was conducted to ensure that intramuscular (IM) diazepam was substituted with IM lorazepam for benzodiazepine rapid tranquillization in inpatient mental health care. We monitored the prescription and administration of medication for rapid tranquillization before (N = 371), during (N = 1130) and after (N = 364) the QI intervention. Seven iterative PDSA cycles with a multiple-component intervention approach were conducted to gradually turn the prescribing practice in the desired direction. Simultaneously, a standard monitoring regimen was introduced to ensure patient safety., Results: Lorazepam administrations gradually replaced diazepam during the intervention period which was sustained post-intervention where lorazepam comprised 96% of benzodiazepine administrations for rapid tranquillization. The mean dose of benzodiazepine administered remained stable from pre (14.40 mg diazepam equivalents) to post (14.61 mg) intervention phase. Close to full compliance (> 80%) with vital signs monitoring was achieved by the end of the observation period., Conclusion: It was possible to increase the quality of treatment of acute agitation in a large inpatient mental health care setting using a stepwise approach based on iterative PDSA cycles and continuous data feedback. This approach might be valuable in other prescribing practice scenarios with feedback from local stakeholders and opinion leaders., (© 2023. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany.)

Objectives: The aim of this study was to estimate drug prescription indicators in outpatient services provided at Iran Social Security Organization (SSO) healthcare facilities., Methods: Data on all prescribed drugs for outpatient visits from 2017 to 2018 were extracted from the SSO database. The data were categorized into 4 main subgroups: patient characteristics, provider characteristics, service characteristics, and type of healthcare facility. Logistic regression models were used to detect risk factors for inappropriate drug prescriptions. SPSS and IBM Modeler software were utilized for data analysis., Results: In 2017, approximately 150 981 752 drug items were issued to outpatients referred to SSO healthcare facilities in Iran. The average number of drug items per outpatient prescription was estimated at 3.33. The proportion of prescriptions that included an injection was 17.5%, and the rate of prescriptions that included an antibiotic was 37.5%. Factors such as patient sex and age, provider specialty, type of facility, and time of outpatient visit were associated with the risk of inappropriate prescriptions., Conclusions: In this study, all drug prescription criteria exceeded the recommended limits set by the World Health Organization. To improve the current prescription patterns throughout the country, it would be beneficial to provide providers with monthly and annual reports and to consider implementing some prescription policies for physicians.

Aims: The purpose of this work was to assess failures in the advanced prescription of parenteral anticancer agents in an adult day oncology care unit with more than 100 patients per day., Methods: An a priori descriptive analysis was carried out by using the risk matrix approach. After defining the scope in a multidisciplinary meeting, we determined at each step the failure modes (FMs), their effects (E) and their associated causes (C). A severity score (S) was assigned to all effects and a probability of occurrence (O) to all causes. These S and O indicators, were used to obtain a criticality index (CI) matrix. We assessed the risk control (RC) of each failure in order to define a residual criticality index (rCI) matrix., Results: During risk analysis, 14 FMs were detected, and 61 scenarios were identified considering all possible effects and causes. Nine situations (15%) were highlighted with the maximum CI, 18 (30%) with a medium CI, and 34 (55%) with a negligible CI. Nevertheless, among all these critical situations, only three (5%) had an rCI to process (i.e., missed dose adjustment, multiple prescriptions and abnormal biology data); the others required monitoring only. Clinicians' and pharmacists' knowledge of these critical situations enables them to manage the associated risks., Conclusions: Advanced prescription of injectable anticancer drugs appears to be a safe practice for patients when combined with risk management. The major risks identified concerned missed dose adjustment, prescription duplication and lack of consideration for abnormal biology data., (© 2024 The Authors. British Journal of Clinical Pharmacology published by John Wiley & Sons Ltd on behalf of British Pharmacological Society.)

Importance: Dermatologists prescribe more oral antibiotics per clinician than clinicians in any other specialty. Despite clinical guidelines that recommend limitation of long-term oral antibiotic treatments for acne to less than 3 months, there is little evidence to guide the design and implementation of an antibiotic stewardship program in clinical practice., Objective: To identify salient barriers and facilitators to long-term antibiotic prescriptions for acne treatment., Design, Setting, and Participants: This qualitative study assessed data collected from stakeholders (including dermatologists, infectious disease physicians, dermatology resident physicians, and nonphysician clinicians) via an online survey and semistructured video interviews between March and August 2021. Data analyses were performed from August 12, 2021, to January 20, 2024., Main Outcomes and Measures: Online survey and qualitative video interviews developed with the Theoretical Domains Framework. Thematic analyses were used to identify salient themes on barriers and facilitators to long-term antibiotic prescriptions for acne treatment., Results: Among 30 participants (14 [47%] males and 16 [53%] females) who completed the study requirements and were included in the analysis, knowledge of antibiotic guideline recommendations was high and antibiotic stewardship was believed to be a professional responsibility. Five salient themes were to be affecting long-term antibiotic prescriptions: perceived lack of evidence to justify change in dermatologic practice, difficulty navigating patient demands and satisfaction, discomfort with discussing contraception, iPLEDGE-related barriers, and the absence of an effective system to measure progress on antibiotic stewardship., Conclusions and Relevance: The findings of this qualitative study indicate that multiple salient factors affect long-term antibiotic prescribing practices for acne treatment. These factors should be considered in the design and implementation of any future outpatient antibiotic stewardship program for clinical dermatology.

Background: Opioid over-prescription is wasteful and contributes to the opioid crisis. We implemented a personalized tiered discharge opioid protocol and education on opioid disposal to minimize over-prescription., Objective: To evaluate the intervention by investigating opioid use post-discharge for women undergoing abdomino-pelvic surgery, and patient adherence to opioid disposal education., Methods: We analyzed post-discharge opioid consumption among 558 patients. Eligible patients included those who underwent elective gynecologic surgery, were not taking scheduled opioids pre-operatively, and received discharge opioids according to a tiered prescribing algorithm. A survey assessing discharge opioid consumption and disposal safety knowledge was distributed on post-discharge day 21. Over-prescription was defined as >20% of the original prescription left over. Descriptive statistics were used for analysis., Results: The survey response rate was 61% and 59% in the minimally invasive surgery and open surgery cohorts, respectively. Overall, 42.8% of patients reported using no opioids after hospital discharge, 45.2% in the minimally invasive surgery and 38.6% in the open surgery cohort. Furthermore, 74.9% of respondents were over-prescribed, with median age being statistically significant for this group (p=0.004). Finally, 46.4% of respondents expressed no knowledge regarding safe disposal practices, with no statistically significant difference between groups (p>0.99)., Conclusion: Despite implementation of the tiered discharge opioid algorithm aimed to personalize opioid prescriptions to estimated need, we still over-prescribed opioids. Additionally, despite targeted education, nearly half of all patients who completed the survey did not know how to dispose of their opioid tablets. Additional efforts are needed to further refine the algorithm to reduce over-prescription of opioids and improve disposal education., Competing Interests: Competing interests: None declared., (© IGCS and ESGO 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Introduction: Prescription is the node of medication management and use that most frequently presents medication errors, according to various studies. This study aims to analyze prescriptions before and after the incorporation of a multidisciplinary round in the pediatric intensive care area and its implication in the occurrence of adverse drug events., Methods: This is an uncontrolled before and after study., Results: 100 patients were studied before and 100 after, range 1-17 years, mean age: 6.4 SD: 8.7. 55.5% (n = 111) were men. A prescription error was detected before the intervention of 12% (n = 12) and after 0% of the intervention, 0%, p = 0.001. A total of 45 adverse events were detected, that is, 45 adverse events per 100 admissions and 38, that is, 38 events per 100 admissions, before and after the intervention respectively (p > 0.05)., Conclusion: The intervention was useful to reduce prescription error in this sample of patients.

Background: The lack of evidence-based guidelines for postoperative opioid prescriptions following breast reconstruction contributes to a wide variation in prescribing practices and increases potential for misuse and abuse., Methods: Between August and December 2019, women who underwent outpatient breast reconstruction were surveyed 7-10 days before (n = 97) and after (n = 101) implementing a standardized opioid prescription reduction initiative. We compared postoperative opioid use, pain control, and refills in both groups. Patient reported outcomes were compared using the BREAST-Q physical wellbeing of the chest domain and a novel symptom Recovery Tracker., Results: Before changes in prescriptions, patients were prescribed a median of 30 pills and consumed three pills (interquartile range [IQR: 1,9]). After standardization, patients were prescribed eight pills and consumed three pills (IQR: 1,6). There was no evidence of a difference in the proportion of patients experiencing moderate to very severe pain on the Recovery Tracker or in the early BREAST-Q physical wellbeing of the chest scores (p = 0.8 and 0.3, respectively)., Conclusion: Standardizing and reducing opioid prescriptions for patients undergoing reconstructive breast surgery is feasible and can significantly decrease the number of excess pills prescribed. The was no adverse impact on early physical wellbeing, although larger studies are needed to obtain further data., (© 2023 Wiley Periodicals LLC.)

Pain is one of the most common symptoms experienced by patients living with cancer. Guidelines recommend opioids as the mainstay in the management of cancer-related pain. However, the opioid epidemic has resulted in policymakers recommending limitations on opioid prescribing which led to community pharmacies implementing various parameters. These restrictions have created barriers for patients with cancer-related pain attempting to fill opioid prescriptions from their community pharmacies. Additionally, in the setting of the opioid epidemic, there have been reports of systemic bias within community pharmacies, leading to experiences with embarrassment and shame for patients with cancer-related pain. This case series presents specific examples of community pharmacies declining to fill opioid prescriptions for patients with cancer-related pain and associated patient suffering., Competing Interests: Disclosures and Acknowledgments This research received no specific funding/grant from any funding agency in the public, commercial, or not-for-profit sectors. The authors declare no conflicts of interest., (Copyright © 2023. Published by Elsevier Inc.)

Older adults are likely to develop adverse drug events owing to age-related changes in pharmacokinetics and polypharmacy. In terms of pharmacokinetics, the drug should be prescribed at a reduced dose, which should be reconsidered and reduced during long-term use. For polypharmacy, "List of drugs to be prescribed with special caution" should be referred and deprescription should be practiced in consideration of the priority of treatment. Because older adults often show reduced ability to manage their medication due to cognitive dysfunction, low visual acuity, and hearing loss, measures should be taken to maintain their adherence.

Objectives: To assess the degree to which removal of FDA' Pregnancy Categories (PC) of medications (A, B, C, and D) from labeling, affects the likelihood that providers will prescribe those medications., Methods: Over a one-year period a convenience sample of providers was recruited into a randomized, survey-based, study. Two versions of the survey were randomly distributed; version 1 presented clinical vignettes, drug information, and PC, while version 2, presented the identical information without the PC. Respondents were asked to estimate their likelihood of prescribing the drug. A mixed linear model was constructed, with likelihood of prescription as the dependent variable, treated as interval-scaled., Results: Out of 169 surveys given out, 162 (96%) were returned. Simple effects analysis showed that the presence of PC letter significantly affected the decision to prescribe category B (p<0.001) and C drugs (p=0.008) but not the A or D. Participants were significantly less likely to prescribe class B and C drugs when the letters were not available for review. These findings remained significant even when controlling for covariates (p=0.001)., Conclusions: When a PC letter is absent on labeling, physicians were less likely to use category B and C drugs, the most common medications prescribed in pregnancy., (© 2022 Walter de Gruyter GmbH, Berlin/Boston.)

Background: Enhanced Recovery After Surgery programs have been shown to effectively reduce opioid prescriptions at discharge after their implementation in several institutions, but little is known regarding the sustainability of this effect. Understanding opioid prescribing patterns after long-term implementation of Enhanced Recovery After Surgery initiatives may help guide further opioid prescription reduction and improvements. Our group aimed to determine whether reductions in opioid prescriptions at discharge are sustained in an Enhanced Recovery After Surgery program for thoracic surgery., Methods: This retrospective cohort included 2,081 patients undergoing thoracic surgery within a 4-year Enhanced Recovery After Surgery program from March 2016 through April 2020. Our Enhanced Recovery After Surgery protocol included a standardized multimodal analgesic regimen (ie, preoperative gabapentin, tramadol, intercostal nerve block with liposomal bupivacaine, and intraoperative acetaminophen, and ketorolac) and the rest of the interventions recommended by the Enhanced Recovery After Surgery society guidelines. Our primary outcomes were the presence of opioid prescriptions at discharge (hydrocodone, hydromorphone, and oxycodone) and the total opioid amount prescribed (morphine equivalent daily dose). Multilevel generalized linear models were used to account for surgeon variabilities and types of thoracic resection., Results: Over the study period, the rate of opioid prescriptions at discharge reduced from 35% (Mar 2016) to 25% (Apr 2020), and the amount of opioid prescribed declined from 184 ± 321 morphine equivalent daily dose to 94 ± 251 morphine equivalent daily dose. In multilevel generalized linear models, there was a sustained downward trend in opioid prescriptions over the study period (β -11.8 morphine equivalent daily dose per year, P = .048), which was also directly correlated with the use of minimally invasive surgery (β -84.9 morphine equivalent daily dose for video-assisted thoracoscopic surgery, P < .001; β -139.2 morphine equivalent daily dose for robotic-assisted thoracic surgery, P < .001), intraoperative opioid administration (β -1.4 morphine equivalent daily dose per 1 morphine equivalent dose, P = .026), and the amount of postoperative acetaminophen (β -18.2 morphine equivalent daily dose per 1 g, P = .026). The sustained reduction of opioid prescriptions at discharge did not impact hospital readmission rates within 30 days (odds ratio 1.17, 95% confidence interval 0.86-1.59, P = .306). Subgroup analysis showed a significant, sustained decrease in hydromorphone (β -10.9 morphine equivalent daily dose per year, P = .004), but not for hydrocodone prescriptions (β -5.7 morphine equivalent daily dose per year, P = .168) or oxycodone (β +4.78 morphine equivalent daily dose per year, P = .183)., Conclusion: Our Enhanced Recovery After Surgery program for thoracic surgery contributed to a sustained reduction of opioid prescriptions at discharge, which positively correlated with the duration of its implementation and the use of minimally invasive surgical techniques but was negatively impacted by the amount of intraoperative opioid administration., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Healthcare systems have reached a critical point regarding the question of whether biosimilar substitution should become common practice. To move the discussion forward, the study objective was to investigate the views of experts from medicines agencies and the pharmaceutical industry on the science underpinning interchangeability of biosimilars. We conducted an empirical qualitative study using semi-structured interviews informed by a cross-disciplinary approach encompassing regulatory science, law, and pharmaceutical policy. In total 25 individuals with experience within biologics participated during September 2018-August 2019. Eight participants were EU national medicines authority regulators, and 17 had pharmaceutical industry background: five from two originator-only companies, four from two companies with both biosimilar and originator products, and eight from seven biosimilar-only companies. Two analysts independently conducted inductive content analysis, resulting in data-driven themes capturing the meaning of the data. The participants reported that interchangeability was more than a scientific question of likeness between biosimilar and reference products: it also pertained to regulatory practices and trust. Participants were overall confident in the science behind exchanging biosimilar products for the reference products via switching, i.e., with physician involvement. However, their opinions differed regarding the scientific risk associated with biosimilar substitution, i.e., without physician involvement. Almost all participants saw no need for additional scientific data to support substitution. Moreover, the participants did not believe that switching studies, as required in the US, were appropriate for obtaining scientific certainty due to their small size. It is unclear why biosimilar switching is viewed as scientifically safer than substitution; therefore, we expect greater policy debate on biosimilar substitution in the near future. We urge European and UK policymakers and regulators to clarify their visions for biosimilar substitution; the positions of these two frontrunners are likely to influence other jurisdictions on the future of biosimilar use., Competing Interests: I have read the journal’s policy and the authors of this manuscript have the following competing interests: LCD was funded by a PhD fellowship grant to the University of Copenhagen from LEO Pharma A/S, but the company has no commercial interest in the research. This does not alter our adherence to PLOS ONE policies on sharing data and materials. ” There are data restrictions which we have described in the data availability statement: “The minimal data set underlying the results has been supplied in the manuscript (the quotes are raw data), additional data cannot be shared publicly because this would compromise anonymity and confidentiality of the participants.

While U.S. opioid prescribing has decreased 38% in the past decade, opioid deaths have increased 300%. This opioid paradox is poorly recognized. Current approaches to opioid management are not working, and new approaches are needed. This article reviews the outcomes and shortcomings of recent U.S. opioid policies and strategies that focus primarily or exclusively on reducing or eliminating opioid prescribing. It introduces concepts of a prescription opioid ecosystem and opioid pool, and it discusses how the pool can be influenced by supply-side, demand-side, and opioid returns factors. It illuminates pressing policy needs for an opioid ecosystem that enables proper opioid stewardship, identifies associated responsibilities, and emphasizes the necessity of making opioid returns as easy and common as opioid prescribing, in order to minimize the size of the opioid pool available for potential diversion, misuse, overdose, and death. Approaches are applicable to opioid prescribing in general, and to opioid prescribing after surgery., (Copyright © 2021, the American Society of Anesthesiologists. All Rights Reserved.)

Purpose/background: Although the prevalence of mental disorders in prisoners is known to be higher than in the general population, less is known about the antipsychotic (AP) prescribing rate in jail. The aim of this research was to investigate prevalence and appropriateness of AP prescription in an Italian prison to expand our understanding on this crucial area of clinical-forensic practice., Methods/procedures: A cross-sectional (census day) design was used among male adults in the Parma Penitentiary Institutes (PPI). Sociodemographic, clinical and prescription data were collected from the PPI electronic clinical database management system. The AP prescribing appropriateness was examined in accordance with the therapeutic indications included in the Italian National Formulary. A descriptive statistical analysis was performed., Findings/results: A total of 98 (14.1%) of 696 PPI prisoners were taking AP medications. Moreover, 90 (91.8%) of the 98 PPI participants were also taking other psychotropic medications concurrently. Quetiapine and olanzapine were the most common prescribed APs. Antipsychotic medications were most likely to be prescribed for off-label indications (74.4%). Less than one fifth of all AP prescriptions were for psychotic disorders., Implications/conclusions: Antipsychotic medications are widely used in prison, often together with other psychotropic drugs. Considering their common adverse effects, it is crucial to longitudinally monitor their potential risk of metabolic, cardiovascular, and extrapyramidal symptoms and signs, as well as their early risk of mortality. Given the high prevalence of AP off-label prescription, the rationale for AP prescribing should be clearly documented and regularly reviewed within the prison by mental health professionals., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Objectives: There has been increased focus nationally on limiting opioid prescriptions. National data demonstrates a decrease in annual opioid prescriptions among emergency medicine physicians. We analyzed data from 2012 to 2020 from a large academic health system in California to understand trends in opioid prescribing patterns for emergency department (ED) discharged patients and assessed the potential impact of two initiatives at limiting local opioid prescriptions., Methods: In 2012-2020, monthly ED visit data was used to evaluate the total number of outpatient opioid prescriptions and percent of ED visits with opioid prescriptions (as primary outcomes). Descriptive statistics, graphic representation, and segmented regression with interrupted times series were used based on two prespecified time points associated with intensive local initiatives directed at limiting opioid prescribing1) comprehensive emergency medicine resident education and 2) electronic health record (EHR)-based intervention., Results: Between March 2012 and July 2020, a total of 41,491 ED discharged patients received an opioid prescription. The three most commonly prescribed drugs were hydrocodone (84.1%), oxycodone (10.8%), and codeine (2.8%). After implementing comprehensive emergency medicine resident education, the total number of opioid prescriptions, the percentage of opioid prescriptions over total ED visit numbers and the total tablet number showed decreasing trends (p's ≤ 0.01), in addition to the natural (pre-intervention) decreasing trends. In contrast, later interventions in the EHR tended to show attenuated decreasing trends., Conclusions: From 2012 to 2020, we found that total opioid prescriptions decreased significantly for discharged ED patients. This trend is seen nationally. However, our specific interventions further heightened this downward trend. Evidence-based legislation, policy changes, and educational initiatives that impact prescribing practices should guide future efforts., Competing Interests: Declaration of Competing Interest No other funding or conflict of interest to report by authors., (Published by Elsevier Inc.)