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Background: Potentially inappropriate medications (PIMs) are medications whereby the harms may outweigh the benefits for a given individual. Although overprescribed to older adults, their direct costs on the healthcare system are poorly described., Methods: This was a cross-sectional study of the cost of PIMs for Canadians aged 65 and older, using adapted criteria from the American Geriatrics Society. We examined prescription claims information from the National Prescription Drug Utilization Information System in 2021 and compared these with 2013. The overall levels of inflation-adjusted total annual expenditure on PIMs, average cost per quarterly exposure, and average quarterly exposures to PIMs were calculated in CAD$., Results: Exposure to most categories of PIMs decreased, aside from gabapentinoids, proton pump inhibitors, and antipsychotics, all of which increased. Canadians spent $1 billion on PIMs in 2021, a 33.6% reduction compared with 2013 ($1.5 billion). In 2021, the largest annual expenditures were on proton pump inhibitors ($211 million) and gabapentinoids ($126 million). The quarterly amount spent on PIMs per person exposed decreased from $95 to $57. In terms of mean cost per person, opioids and antipsychotics were highest ($138 and $118 per exposure). Some cost savings may have occurred secondary to an observed decline of 16.4% in the quarterly rate of exposure to PIMs (from 7301 per 10,000 in 2013 to 6106 per 10,000 in 2021)., Conclusions: While expenditures on PIMs have declined in Canada, the overall cost remains high. Prescribing of some seriously harmful classes of PIMs has increased and so directed, scalable interventions are needed., (© 2024 The Author(s). Journal of the American Geriatrics Society published by Wiley Periodicals LLC on behalf of The American Geriatrics Society.)

Background: The Screening Tool of Older Persons Prescriptions in Frail adults with limited life expectancy (STOPPFrail) criteria aim to reduce inappropriate/unnecessary medications in frail older adults, which should minimise adverse drug events and additional healthcare expenditure. Little is known about the economic outcomes of applying these criteria as an intervention., Aim: To evaluate cost avoidance of pharmacist-led application of STOPPFrail to frail older nursing home residents with limited life expectancy., Method: Pharmacist-identified STOPPFrail-defined potentially inappropriate medications that were deprescribed by patients' general practitioners were assigned a rating by a multidisciplinary panel, i.e. the probability of an adverse drug event occurring if the medication was not deprescribed. The intervention's net cost benefit and cost-benefit ratio were then determined by factoring in adverse drug event cost avoidance (calculated from probability of adverse drug event ratings), direct cost savings (deprescribed medication costs/reimbursement fees), and healthcare professionals' salaries., Results: Of the 176 potentially inappropriate medications deprescribed across 69 patients, 65 (36.9%) were rated as having a medium or high probability of an adverse drug event occurring if not deprescribed. With €27,162 for direct cost savings, €61,336 for adverse drug event cost avoidance, and €2,589 for healthcare professionals' salary costs, there was a net cost benefit of €85,909 overall. The cost-benefit ratio was 33.2 and remained positive in all scenarios in sensitivity analyses., Conclusion: Pharmacist-led application of STOPPFrail to frail older nursing home residents is associated with significant cost avoidance. Wider implementation of pharmacist interventions in frail older nursing home residents should be considered to reduce potentially inappropriate medications and patient harm, alongside substantial cost savings for healthcare systems., (© 2024. The Author(s).)

Background: Potentially inappropriate prescribing (PIP) refers to the prescription of medications that carry a higher risk of adverse outcomes, such as drug interactions, falls, and cognitive impairment. PIP is of particular concern in older adults, and is associated with increased morbidity, mortality, and healthcare costs. Socioeconomic deprivation has been identified as a potential risk factor for PIP. However, the extent of this relationship remains unclear. This review aimed to synthesize the current literature on the association between PIP and socioeconomic status (SES) in older adults., Methods: A literature search was conducted using the databases Medline, Embase and CINAHL. A search strategy was developed to capture papers examining three key concepts: PIP, socioeconomic deprivation and older/elderly populations. Peer-reviewed quantitative research published between 1/1/2000 and 31/12/2022 was eligible for inclusion., Results: Twenty articles from 3,966 hits met the inclusion criteria. The sample size of included studies ranged from 668 to 16.5million individuals, with the majority from Europe (n = 8) and North America (n = 8). Most defined older patients as being 65 or over (n = 12) and used income (n = 7) or subsidy eligibility (n = 5) to assess SES. In all, twelve studies reported a statistically significant association between socioeconomic deprivation and an increased likelihood of experiencing PIP. Several of these reported some association after adjusting for number of drugs taken, or the presence of polypharmacy. The underlying reasons for the association are unclear, although one study found that the association between deprivation and higher PIP prevalence could not be explained by poorer access to healthcare facilities or practitioners., Conclusion: The findings suggest some association between an older person's SES and their likelihood of being exposed to PIP. SES appears to be one of several factors that act independently and in concert to influence an older person's likelihood of experiencing PIP. This review highlights that prioritising older people living in socioeconomically-deprived circumstances may be an efficient strategy when carrying out medication reviews., (© 2024. The Author(s).)

Objectives: To quantify prevalence, harms, and NHS costs in England of problematic oral non-steroidal anti-inflammatory drug (NSAID) prescribing in high risk groups., Design: Population based cohort and economic modelling study., Setting: Economic models estimating patient harm associated with NSAID specific hazardous prescribing events, and cost to the English NHS, over a 10 year period, were combined with trends of hazardous prescribing event to estimate national levels of patient harm and NHS costs., Participants: Eligible participants were prescribed oral NSAIDs and were in five high risk groups: older adults (≥65 years) with no gastroprotection; people who concurrently took oral anticoagulants; or those with heart failure, chronic kidney disease, or a history of peptic ulcer., Main Outcome Measures: Prevalence of hazardous prescribing events, by each event and overall, discounted quality adjusted life years (QALYs) lost, and cost to the NHS in England of managing harm., Results: QALY losses and cost increases were observed for each hazardous prescribing event ( v no hazardous prescribing event). Mean QALYs per person were between 0.01 (95% credibility interval (CI) 0.01 to 0.02) lower with history of peptic ulcer, to 0.11 (0.04 to 0.19) lower with chronic kidney disease. Mean cost increases ranged from a non-statistically significant £14 (€17; $18) (95% CI -£71 to £98) in heart failure, to a statistically significant £1097 (£236 to £2542) in people concurrently taking anticoagulants. Prevalence of hazardous prescribing events per 1000 patients ranged from 0.11 in people who have had a peptic ulcer to 1.70 in older adults. Nationally, the most common hazardous prescribing event (older adults with no gastroprotection) resulted in 1929 (1416 to 2452) QALYs lost, costing £2.46m (£0.65m to £4.68m). The greatest impact was in people concurrently taking oral anticoagulants: 2143 (894 to 4073) QALYs lost, costing £25.41m (£5.25m to £60.01m). Over 10 years, total QALYs lost were estimated to be 6335 (4471 to 8658) and an NHS cost for England of £31.43m (£9.28m to £67.11m)., Conclusions: NSAIDs continue to be a source of avoidable harm and healthcare cost in these five high risk populations, especially in inducing an acute event in people with chronic condition and people taking oral anticoagulants., Competing Interests: Competing interests: All authors have completed the ICMJE uniform disclosure form at www.icmje.org/disclosure-of-interest/ and declare: Funding from the NIHR; DMA reports research grants from NIHR, AbbVie, Almirall, Celgene, Eli Lilly, Janssen, Novartis, UCB, and the Leo Foundation. AC, EC, BG, DM, LP, and GR report research grants from NIHR. AC reports research grants from NIHR, UKRI, and Industrial Challenge Fund. AJA reports research grants from NIHR and was National Clinical Director for NHS England at the time of the study. RAE reports research grants from NIHR and Abbott., (© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY. No commercial re-use. See rights and permissions. Published by BMJ.)

Law 405/2001, DGR of 30 July 2012, n. 45-4248 and the DGR of 2 August 2013, n. 85-6287 provide that ASLs guarantee the direct distribution of drugs from the Company's Therapeutic Handbook (PTA) necessary for the treatment of patients in residential and semi-residential care. In this context, some critical issues have emerged such as: long dispensing times with repercussions of "extemporaneous" prescriptions in the area by GPs and consequent disbursements under contract (CONV) and distribution on behalf (DPC), poorly controlled stocks of medicines within the structures, lack of appropriateness of therapies, significant increase in costs. The final objective is to describe the process of supplying and managing medicines for guests hospitalized in facilities for the elderly and disabled (here in after RSA) and identify strategies to optimize appropriateness pathways. METHODS In 2022, there were 46 RSAs present in ASL VC, of which 31 were enrolled in the project and for which a retrospective descriptive study was conducted. Each RSA sends an Excel and a PDF (stamped and signed by the GP) of the drug request to the SC Farmaceutica Territoriale (SFT). The request indicates: date of completion, GP, tax code/patient name, surname, drug, quantity, dosage, AIFA note, any notes. The SFT checks the requests for quantity (packages requested/indicated dosage) and quality (prescriptive appropriateness) and forwards them to the Hospital Pharmacy for processing. RESULTS From 2019 to 2022, enrollment grew from 18 to 31 RSAs and guests from 1,387 to 1,678 with an average age of 83.84 (± 11.64); at the same time, there was a reduction in the average number of drugs given to patients from 62.5 to 47.3 and in prescriptions per patient from 32.8 to 31.7. Over the years the percentage of checks carried out by the SFT has increased from 2% to 5%. The most frequent inappropriatenesses were: lack of known AIFA (22.5%), missing PT (12.3%), drugs outside PTA (11.2%), expired PT (9.3%), absence of diagnosis (6.5%). The gross per capita affiliated pharmaceutical expenditure of €163.83 in 2019 fell to €136.97 in 2022 (-19%). The DPC increased from €27.83 to €38.80 in relation to the expansion of the drugs included in the PHT. DISCUSSION The project guarantees, through prescriptive appropriateness paths, a more controlled and punctual supply of the drug with a consequent reduction in the expenditure paid by the NHS. It also highlights the importance of the figure of the pharmacist, as a drug specialist, for the correct management and organization of procedures aimed at obtaining favorable results such as the deprescribing of drugs. CONCLUSION The project will continue with the enlistment of other RSAs and the proposal to include the pharmacist in the Supervisory Commission which inspects the structures to evaluate the management of the drug on site to guarantee the protection of patient health.

Background: Irrational pharmacotherapy and increasing pharmacy costs remain major concerns in healthcare systems. Pharmacists are expected to employ diagnosis-related group (DRG) data to analyse inpatient pharmacy utilization., Objective: This project aimed to pilot an efficient pharmacist-led programme to analyse factors related to pharmacy expenses, evaluate the rational use of drugs in batch processing, and make further interventions based on DRG data., Methods: Patients from the OB25 (caesarean section without comorbidities or complications) DRG were selected in 2018, and the most relevant factors were identified through statistical analysis. Interventions were implemented by sending monthly reports on prescribing data and drug review results for the same DRGs to the department starting in 2019. Pre-post comparisons were conducted to demonstrate changes in pharmacy costs and appropriateness at a tertiary teaching hospital with 2,300 beds in China., Results: A total of 1,110 patients were identified from the OB25 DRG data in 2018. Multivariate linear analysis indicated that the number of items prescribed and wards substantially influenced pharmacy expenditure. Drugs labelled as vital, essential, and non-essential revealed that 46.6% of total pharmacy costs were spent on non-essential drugs, whereas 38.7% were spent on vital drugs. The use of inappropriate pharmaceuticals and drug items was substantially reduced, and the average pharmacy cost after intervention was 336.7 RMB in 2020. The benefit-cost ratio of the programme was 9.86., Conclusion: Interventions based on DRG data are highly efficient and feasible for reducing inpatient pharmacy costs and non-essential drug use.

Aims: The aim of this study was to investigate the prevalence of potentially inappropriate medication (PIM) prescribing and its number-dependent association (PIM = 1, 2, ≥3) with all-cause hospitalizations, emergency department (ED) visits, and medication expenditures in Beijing, China., Methods: A retrospective cohort analysis was conducted to analyse PIM prescribing in community-dwelling older adults aged ≥65 years within the Beijing Municipal Medical Insurance Database (data from July to September 2016). The prevalence of PIMs was estimated based on the 2015 Beers Criteria. Logistic models were utilized to investigate the associations between PIM use and all-cause hospitalizations and ED visits. Generalized linear models with the logic link and gamma distribution were used to analyse associations between PIM use and medication expenditures., Results: Among the 506 214 older adults, the prevalence of PIM was 38.07%. After adjusting for covariables, prescribing two and three or more PIMs was associated with increased risks of hospitalizations (PIM = 2: odds ratio [OR] 1.34, 95% confidence interval [CI]: 1.22-1.47; PIM ≥ 3: OR = 1.47, 95% CI: 1.32-1.63) and ED visits (PIM = 2: OR = 1.29, 95% CI 1.12-1.48; PIM ≥ 3: OR = 1.23, 95% CI: 1.04-1.44). Exposures to two and three or more PIMs were associated with higher medication expenditures for inpatient visits (PIM = 2: incidence rate ratio [IRR] = 1.08, 95% CI 1.01-1.16; PIM ≥ 3: IRR = 1.18, 95% CI: 1.08-1.28). Vasodilators were the most frequent PIM prescribing group among patients who were hospitalized or had to visit the ED., Conclusions: PIMs were prescribed at a high rate among community-dwelling older adults in Beijing. Two or more PIMs were associated with increased risks of hospitalizations, ED visits, and increased inpatient medication expenditures. Effective interventions are needed to target unnecessary and inappropriate medications in older adults., (© 2022 British Pharmacological Society.)

Background: Sedative use in older adults increases the risk of falls, fractures, and hospitalizations. The D-PRESCRIBE (Developing Pharmacist-Led Research to Educate and Sensitize Community Residents to the Inappropriate Prescriptions Burden in the Elderly), pragmatic randomized clinical trial demonstrated that community-based, pharmacist-led education delivered simultaneously to older adults and their primary care providers reduce the use of sedatives by 43% over 6 months. However, the associated health benefits and cost savings have yet to be described. This study evaluates the cost-effectiveness of the D-PRESCRIBE intervention compared to usual care for reducing the use of potentially inappropriate sedatives among older adults., Methods: A cost-utility analysis from the public health care perspective of Canada estimated the costs and quality-adjusted life-years (QALYs) associated with the D-PRESCRIBE intervention compared to usual care over a 1-year time horizon. Transition probabilities, intervention effectiveness, utility, and costs were derived from the literature. Probabilistic analyses were performed using a decision tree and Markov model to estimate the incremental cost-effectiveness ratio., Results: Compared to usual care, pharmacist-led deprescribing is less costly (-$1392.05 CAD) and more effective (0.0769 QALYs). Using common willingness-to-pay (WTP) thresholds of $50 000 and $100 000, D-PRESCRIBE was the optimal strategy. Scenario analysis indicated the cost-effectiveness of D-PRESCRIBE is sensitive to the rate of deprescribing., Conclusions: Community pharmacist-led deprescribing of sedatives is cost-effective, leading to greater quality-of-life and harm reduction among older adults. As the pharmacist's scope of practice expands, consideration should be given to interprofessional models of remuneration for quality prescribing and deprescribing services., (© The Author(s) 2020. Published by Oxford University Press on behalf of The Gerontological Society of America. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Objective: To assess economic and social drivers of dispensing antibiotics without prescription by community pharmacies in Nepal., Method: A survey was conducted among 111 pharmacy owners and managers in five districts. Information on demographic and economic characteristics of the pharmacies (e.g. revenue and profits from antibiotics) and their inclination to sell antibiotics without a physician's prescription under various scenarios (e.g. diarrhoea in a child) was collected. Univariate analysis was conducted to assess the demographic and economic characteristics. Bivariate analysis was conducted to examine the relationship between dispensing antibiotics without prescription and economic and social factors., Results: Azithromycin and amoxicillin were the most commonly dispensed antibiotics. The proportions of pharmacies reporting that they would 'most likely' or 'likely' dispense antibiotics without prescription to adult patients ranged from 36.9% (sore throat) to 67.6% (cough). The proportions for paediatric patients ranged from 62.2% (sore throat) to 80.2% (cough or diarrhoea). There was no consistent relationship between the likelihood of dispensing antibiotics and revenues, profits or the number of patients. Instead, dispensing behaviour was influenced by the pressure from the patient; the respondents were more likely to dispense antibiotics when the patient specifically asked for 'an antibiotic' rather than for 'a medicine', and 68.5% respondents ranked 'customer satisfaction' as the most important factor motivating their work., Conclusions: In Nepal, inappropriate sale of antibiotics by community pharmacists is high, particularly for paediatric patients. Additional research is needed to establish key drivers of this behaviour and to help design effective approaches to reducing AMR., (© 2021 John Wiley & Sons Ltd.)

Background: Inappropriate albumin use in clinical practice remains problematic. Health-systems face continued challenges in promoting cost-appropriate use., Objective: To evaluate the clinical and economic impact of a clinical pharmacist-led intervention strategy targeting inappropriate albumin use in general ward patients., Methods: A retrospective cohort study evaluated all adult (≥18 years) general ward patients administered ≥1 dose of albumin at a university medical center over a 2-year period. The intervention consisted of a clinical pharmacist-led strategy intervening on all albumin orders not in accordance with institutional guidelines. The primary end point was to compare inappropriate albumin utilization before and after implementation. Secondary end points compared the rates of inappropriate albumin use adjusted for hospital admission and patient-days as well as associated costs by appropriateness between study periods., Results: A total of 4420 patients were screened, with 1971 (44.6%) patients meeting inclusion criteria. The clinical pharmacist strategy significantly reduced inappropriate albumin (grams) utilization by 86.0% ( P < 0.001). A 7-fold reduction of inappropriate albumin administered adjusted for the number of patient admissions was found from the preimplementation period following clinical pharmacist intervention strategy implementation (415.3 ± 83.2 vs 57.5 ± 34.2 g per 100 general ward hospital admissions, respectively; P < 0.001). Also, the adjusted inappropriate albumin rate was reduced from 62.2 ± 12.3 to 8.6 ± 5.2 g per 100 patient-days in the preimplementation and postimplementation periods, respectively ( P < 0.001). Annual cost savings were $421 455 overall, with $341 930 resulting from mitigation of inappropriate use., Conclusion and Relevance: Clinical pharmacist-led interventions significantly reduced inappropriate albumin use and costs in hospitalized patients.

Objectives : Pubmed literature search show that the prescription of potentially inappropriate medications is a major concern in older hospitalized patients, both from a clinical and financial perspective. This study aims to identify factors associated with exposure and potentially inappropriate medication costs in older hospitalized patients and to assess the financial impact of substituting these medications with safer alternatives. Methods : We performed an observational cross-sectional study of all patients aged 75 years or older hospitalized in a university hospital (except geriatric wards) on a given day. Potentially inappropriate medications were identified using European and French guidelines. Results : A total of 365 patients were included. At least one potentially inappropriate medication was prescribed in 50.4% of these patients. This contributed 19.7% [16.1; 23.6] to the average cost of medication per patient. Substitution of these medications with recommended alternatives was cost saving: average incremental cost per patient: -3.97 € [-7.21; -1.58]. Both polypharmacy and type of ward providing care were associated with increased costs of potentially inappropriate medications. Conclusions : This study assessed the prevalence of potentially inappropriate medications in older hospitalized patients and established that their substitution by alternative medications provided a cost saving.

Objectives: Inappropriate prescribing of medications is common in health care, and is an important safety concern, especially for older adults, who have a high burden of comorbidity and are at greater risk for medication-related adverse events. This study aims to estimate the extent and cost of potentially inappropriate prescribing of medications to older adults in the United States., Design: A cross-sectional study., Setting: Medicare Part D Prescription Drug Program data set (2014-2018)., Participants: Older adults who were enrolled in Medicare Part D Prescription Drug Program between 2014 and 2018., Measurements: Potentially inappropriate medications were identified using the 2019 American Geriatrics Society Beers Criteria®., Results: In 2018, 7.3 billion doses of potentially inappropriate medications were dispensed. The most common medications by number of doses dispensed were proton pump inhibitors, benzodiazepines, and tricyclic antidepressants, and the top five unique medications by reported spending were dexlansoprazole, esomeprazole, omeprazole, dronedarone, and conjugated estrogens. From 2014 to 2018, 43 billion doses of potentially inappropriate medications were dispensed, with a reported spending of $25.2 billion., Conclusion: Potentially inappropriate medication use among older adults is both common and costly. Careful attention to potentially inappropriate medication use and deprescribing when clinically appropriate could reduce costs and potentially improve outcomes among older adults., (© 2020 The American Geriatrics Society.)

Objectives : Adverse drug events (ADE) are a common cause of morbidity and mortality in elderly patients. In this study, we assessed the impact of multidisciplinary medication review (MMR) for nursing home residents on patient safety and costs incurred by the hospital and the national health service. Methods : Medical files of residents were retrospectively assessed for medications prescribed in the previous six months. A pharmacist reviewed the prescriptions and suggested modifications to the patient's medical team. Patients were followed for six months. Trivalle's ADE geriatric risk score was calculated before and after MMR, as were number of potentially inappropriate medications, and economic impact from the perspective of the health care system and the nursing home. Results : Forty-nine patients were recruited. ADE score dropped one risk level (median score of 4 before versus 1 after, p < 0.0001). The number of patients taking at least one potentially inappropriate medication decreased from 30.6% before to 6.1% after MMR (p = 0.005). A mean saving of €232 per patient was made from the nursing home perspective following MMR (p = 0.008). Conclusion : The MMR reduced the iatrogenic drug risk for elderly residents and costs from the nursing home perspective, particularly drug expenditure.

Background and Objectives: Excessive use of antibiotics has been noted in children with respiratory tract infections in Vietnam, but antibiotic use in hospitalised children is poorly documented. Antibiotic use and direct healthcare costs in children hospitalised with pneumonia in central Vietnam were assessed., Methods: A prospective descriptive study of children under 5 years old admitted with a primary admission diagnosis of 'pneumonia' to the Da Nang Hospital for Women and Children over 1 year., Results: Of 2911 children hospitalised with pneumonia, 2735 (94.0%) were classified as 'non-severe' pneumonia by the admitting physician. In total, 2853 (98.0%) children received antibiotics. Intravenous antibiotics were given to 336 (12.3%) children with 'non-severe' and 157/176 (89.2%) children with 'severe' pneumonia; those with 'non-severe' pneumonia accounted for 68.2% (336/493) of intravenous antibiotics given. Only 19.3% (95/493) of children on intravenous antibiotics were stepped down to an oral antibiotic. Cefuroxime was the preferred oral agent, and ceftriaxone was the preferred injectable agent. Hospital admission for oral antibiotics in 'non-severe' pneumonia was a major cost driver, with an average direct cost of US$78.9 per patient, accounting for 54.0% of the total hospitalisation cost in the study cohort. In addition, 336 (12.3%) children with non-severe pneumonia received intravenous antibiotics without indication, accounting for a further 23.2% of hospitalisation costs., Conclusion: Limiting unnecessary hospitalisation and considering early intravenous to oral step down antibiotic will reduce direct health system costs and morbidity in children with respiratory tract infections in Vietnam., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. No commercial re-use. See rights and permissions. Published by BMJ.)

Objectives: Older adults are often prescribed potentially inappropriate medications associated with adverse health outcomes and increased health services utilization. Developing Pharmacist-led Research to Educate and Sensitize Community Residents to the Inappropriate Prescriptions Burden in the Elderly (D-PRESCRIBE), a pragmatic randomized clinical trial, demonstrated how a community pharmacist-led evidence-based educational intervention successfully empowered community-dwelling older adults and their physicians to reduce chronic use of inappropriate medications. The objective of this study was to evaluate the cost-effectiveness of the D-PRESCRIBE intervention for discontinuing nonsteroidal anti-inflammatory drugs (NSAIDs)., Design: Cost-effectiveness analysis., Setting: Canada., Participants: Community-dwelling adults aged 65 years and older., Measurements: Decision analysis combining decision tree and Markov state transition modeling was developed to estimate the cost-effectiveness of D-PRESCRIBE (NSAIDs) compared with usual care from a Canadian healthcare system perspective with a time horizon of 1 year. Data from the D-PRESCRIBE trial and published literature were used to calculate effectiveness, utilities, and costs. Reference case and scenario analyses were conducted using probabilistic modeling. Sensitivity analyses assessed the robustness of the reference case model., Results: D-PRESCRIBE (NSAIDs) was less costly (-$1008.61) and more effective (.11 quality-adjusted life-years [QALYs]) than usual care and was the dominant strategy. At willingness-to-pay thresholds of $50 000 per QALY and $100 000 per QALY, D-PRESCRIBE (NSAIDs) incurred a positive incremental net benefit compared with usual care, suggesting it is cost-effective. Compared with the reference case, scenario analyses gave comparable QALYs with modest variation in cost estimates., Conclusion: For community-dwelling older adults, D-PRESCRIBE (NSAIDs) provides greater benefits at lower system costs, making it a compelling strategy to reduce the use and harms associated with chronic NSAID consumption. Our findings support reimbursing community pharmacists' clinical professional services for deprescribing inappropriate NSAIDs in community-dwelling older adults. J Am Geriatr Soc 68:1090-1097, 2020., (© 2020 The American Geriatrics Society.)

Antibiotics are widely prescribed and often used irrationally in Chinese hospitals. This study aimed to evaluate the pharmacist's influence on antibiotic use in the pediatric ward. We conducted this pre-to-post intervention study in the pediatrics of a Chinese tertiary hospital. The patients hospitalized from April to June 2018 were assigned to the pre-intervention group and those from April to June 2019 were distributed to post-intervention group. In the post-intervention stage, the pharmacist took measures to promote rational use of antibiotics and their effects were assessed. This study analyzed data of 1408 patients totally, 671 and 737 in the pre-intervention and post-intervention group respectively. The interventions of clinical pharmacist significantly reduced the rate of using antibiotics without indications (from 33.55% to 15.82%, p<0.01), percentage of inappropriate antibiotic choice (from 24.79% to 16.58%, p p<0.01), dose (from 8.55% to 4.34%, p p<0.05), combination (from 11.75% to 5.10%, p p<0.01) and prolonged duration (from 14.53% to 10.46%, p p<0.05). The mean antibiotic cost and cost/patient-day were also significantly reduced after the intervention. The ratio of average antibiotic cost saving to pharmacist time cost was 16.77:1. The pharmacist could play vital roles in optimizing antibiotic use, thus resulting in favorable clinical and economic outcomes in pediatric ward.

Background: The burden of bacterial infections is huge and grossly under-represented in the current health-care system. Inappropriate use of antimicrobial medicines (AMMs) poses a potential hazard to patients by causing antibiotic resistance. This study was conducted to assess the: (i) AMM consumption and use patterns in patients attending the outpatients and inpatients of Medicine and Surgery departments of the hospital. (ii) Appropriateness of the AMM in the treatment prescribed, and (iii) cost incurred on their use in admitted patients., Materials and Methods: An observational, prospective study was conducted among inpatients and outpatients of the Medicine and Surgery departments of a tertiary care hospital of northern India. Analysis of 2128 prescriptions and 200 inpatient records was performed using a predesigned format. The use of AMMs was reviewed using anatomical therapeutic chemical classification and defined daily doses (DDDs). To evaluate the expenditure incurred on AMMs, ABC analysis was performed., Results: AMMs were prescribed to 37.9% outpatients and 73% of admitted patients. The percentage encounters with AMMs was 40.6% (medicine) and 25.6% (surgery) outpatients. The total DDDs/100 patient days of AMMs in medicine and surgery were 3369 and 2247. Bacteriological evidence of infection and AMM sensitivity was present in only 8.5% of cases. Over 90% of AMMs were prescribed from the hospital essential medicines list. Most of the AMMs were administered parenterally (64.9%). Multiple AMMs were prescribed more to inpatients (84.2% vs. 4.2% outpatients). Overall, expenditure on AMM was 33% of the total cost of treatment on medicine. ABC analysis showed that 74% of the expenditure was due to newer, expensive AMM, which constituted only 9% of the AMM used. The AMM therapy was found to be appropriate in 88% of cases as per Kunin's criteria for rationality., Conclusion: AMMs are being commonly prescribed without confirmation of AMM sensitivity in the hospital. A large proportion of expenditure is being incurred on expensive AMM used in a few number of patients. There is a need for developing a policy for rational use of AMM in the health facility., Competing Interests: There are no conflicts of interest., (Copyright: © 2020 Indian Journal of Pharmacology.)

Objective: Investigation of polypharmacy in patients with type 2 diabetes revealed that medications administered according to the patient's symptoms and complaints strongly contributed to polypharmacy. We explored the effects of clinical ward pharmacy service, which evaluated the need for symptomatic treatment, therefore minimizing polypharmacy by reducing inappropriate medications., Results: The number of drugs (hospitalization vs. discharge: 9 [1-17] vs. 7 [1-16], P < 0.001) and rate of polypharmacy (hospitalization vs. discharge: 75.4% vs. 61.1%, P < 0.001) were significantly lower at discharge. Since hospital admission, the number of drugs increased (n = 6, 11%), remained unchanged (n = 15, 28%), decreased by 1 drug (n = 4, 8%), decreased by 2 drugs (n = 3, 6%), and decreased by more than 2 drugs (n = 25, 47%). Daily drug costs were significantly reduced (hospitalization vs. discharge: $8.3 vs. $6.1, P < 0.001).

Background: Antibiotics are often prescribed inappropriately to patients with upper respiratory infection (URI) in ambulatory care settings; however, the economic burden of such prescription has not been quantitatively assessed. Here, we aimed to evaluate the additional cost of antimicrobial prescription for URI at the population level in Japan., Methods: We conducted a retrospective observational survey using longitudinal claims data between 2013 and 2016 obtained from JMDC Claims Database, which contains data from 5·1 million corporate employees and family members under the age of 65 years. Appropriateness of antibiotic prescription was assessed by a panel of six infectious disease physicians according to ICD-10 code in JMDC Claims Database. Total additional cost of antibiotic prescription for URI at the national level was estimated by weighting of age-structured population data., Results: The annual additional cost of inappropriate antibiotic prescription for URI was estimated at 423·6 (95% CI: 416·8-430·5) million USD in 2013, 340·9 (95% CI: 335·7-346·2) million USD in 2014, 349·9 (95% CI: 344·5-355·3) million USD in 2015, and 297·1 (95% CI: 292·4-301·9) million USD in 2016. Three classes of broad-spectrum oral antibiotics (third-generation cephalosporins, macrolides, and fluoroquinolones) accounted for > 90% of the total additional cost., Conclusions: Although a decreasing trend was observed, annual additional costs of inappropriate antibiotic prescriptions for URI could be a substantial economic burden in Japan. Appropriately prescribing broad-spectrum oral antibiotics might be an important issue to reduce unnecessary medical costs in Japanese ambulatory care.

Background: Optimal albumin use in the intensive care unit (ICU) remains challenging with inappropriate use approaching 50%. No published reports have described clinical pharmacist impact aimed at mitigating inappropriate albumin use in the ICU. Objective: To evaluate the clinical and economic impact of a clinical pharmacist-led intervention strategy targeting inappropriate albumin in the ICU. Methods: A retrospective cohort study evaluated all adult (≥18 years) ICU patients administered albumin at an academic medical center over a 2-year period. Institutional guidelines were developed with clinical pharmacists targeting inappropriate albumin use. The primary end point was to compare inappropriate use of albumin administered before and after pharmacist intervention implementation. Secondary analyses compared the overall albumin use between study periods. In-hospital mortality, length of stay, and albumin-related costs between study periods were also compared. Results: A total of 4419 patients were identified, with 2448 (55.4%) critically ill patients included. The pharmacist-led strategy resulted in a 50.9% reduction of inappropriate albumin use ( P < 0.001). The rate of inappropriate albumin use was 44.3 ± 10.5 and 5.5 ± 2.9 g per patient-day in the preimplementation and postimplementation periods, respectively ( P < 0.001). Costs associated with overall and inappropriate albumin use in the ICU decreased by 34.8% and 87.1%, respectively. Total annual cost-savings was $355 393 in the ICUs. No differences in clinical outcomes were found. Conclusion and Relevance: Clinical pharmacist-led interventions reduced overall and inappropriate albumin use and costs without negatively affecting clinical outcomes.

Background: Human albumin is an expensive therapy with inappropriate use in many clinical conditions. Inappropriate use of albumin imposes a substantial economic burden on the healthcare system and society. Drug use evaluation (DUE) is one method of assessing the appropriateness of drug use which has been powered by increasing concern about the cost-effectiveness of drugs. The objective of this study is to systematically review the appropriateness of albumin utilization in Iranian hospitals., Methods: We searched the PubMed, MEDLINE, EMBASE, SCOPUS, and Google Scholar for articles in English and SID, Magiran, Medlib, and Irandoc for articles in Persian from 1997 to 2018. Studies on the DUE of albumin in Iranian hospitals were included in this study. Articles conducted outside Iran, editorials, letters and review articles were excluded., Results: In total, eight studies were selected for the final review. The majority of the papers were conducted in Tehran. In most studies, the highest albumin consumption was related to the intensive care unit. The most frequent reasons for prescribing albumin were edema, hypoalbuminemia, volume expansion after heart surgery, ascites, cardiac surgery and cirrhosis. Of the studies included, five studies evaluated the costs of drug use., Conclusion: Our findings show that inappropriate use of albumin imposes a relatively high additional cost on the society. The included studies show that the percentage of inappropriate use of albumin is relatively high in Iran and this abuse is an essential problem in Iranian hospitals. Prescription based on standard guidelines could improve rational use of albumin and lead to savings in treatment costs., (© 2019 The Author(s). This is an open-access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.)

Objectives : Inappropriate prescription is a problem related to aging and deprescription could be a possible strategy. The aim of this study was to adapt the available evidence on deprescribing to the medication management of older people living in long-term care facilities. Methods : The authors carried out a bibliographic search based on the most prevalent drugs in our context to develop a specific deprescribing intervention. A committee of experts reviewed this intervention which was later validated through an interobserver variability study. Finally, the authors evaluated it in a sample of patients through a controlled before-after study. Results : The authors included 119 subjects living in a public elderly long-term care center and 122 controls living in a center with similar clinical characteristics. The authors evaluated 852 medications, identifying a total of 175 (20.5%) potentially inappropriate medications and 162 (92.5%) drugs were deprescribed (1.4 per patient). The application of the intervention meant an annual saving of 9.525.25 €. Conclusion : The implementation of a deprescribing intervention aimed at the most prevalent drugs prescribed in a particular setting improves the appropriateness of pharmacotherapy in the patients.

Objectives: To assess the budget impact of restricting inappropriate inhaled corticosteroids (ICS) use according to the Global Initiative for Chronic Obstructive Lung Disease (GOLD)-guidelines indication for ICS use in the chronic obstructive pulmonary disease (COPD)-population, taking The Netherlands as a reference case., Methods: A budget impact model was developed and closely aligned with the International Society for Pharmacoeconomics and Outcomes Research best-practice guidelines. The model estimates the impact of pharmacologic COPD maintenance treatments on clinical events (exacerbations and pneumonias) and associated healthcare utilization and costs. The current treatment mix included all maintenance treatments including long-acting muscarinic antagonists (LAMA), long-acting β2-agonists (LABA), LABA/ICS, LABA/LAMA, and triple therapy (LABA/LAMA/ICS). We modeled a situation where 25% of patients would use ICS-containing treatments and compared this to the current Dutch situation with 60% ICS use. A 5-year time horizon with a Dutch healthcare payer's perspective was used. In sensitivity analyses, a range of values for absolute ICS reduction (20%-40%), relative risks of exacerbations and pneumonia events, and other input parameters were explored., Results: Over a period of 5 years, the new treatment mix with Global Initiative for Chronic Obstructive Lung Disease guideline recommended ICS, and LABA/LAMA use resulted in potential avoidance of 17 405 exacerbations and 11 984 pneumonias and accompanied savings of €84 million in the base-case scenario. Savings were consistent in various sensitivity analyses, indicating cost savings between €30 and €200 million., Conclusion: Reducing inappropriate ICS use and increasing use of LABA/LAMA in COPD patients could result in a reduction of exacerbations and pneumonias, corresponding with a reduction in total costs for COPD in The Netherlands., (Copyright © 2019 ISPOR–The Professional Society for Health Economics and Outcomes Research. Published by Elsevier Inc. All rights reserved.)

Aim: To quantify (i) indicated versus non-indicated prescribing of acid-suppression therapies (AST) in a tertiary paediatric hospital; (ii) patient, provider and hospital factors associated with non-indicated prescribing; and (iii) medication costs., Methods: This was a prospective, electronic medical audit conducted at The Royal Children's Hospital (RCH) Melbourne in August-September 2016. Proton pump inhibitor (PPI) and histamine-2 receptor antagonist (H 2 RA) prescriptions were extracted, with relevant patient, provider and hospital data. Logistic regression analysis of variables associated with indicated and non-indicated prescribing was undertaken. Costs of indicated and non-indicated prescriptions were estimated, with annual costs projected., Results: There was more non-indicated than indicated prescribing across inpatient, outpatient and emergency department settings. Of the total 303 prescriptions analysed, 238 (78.5%) were non-indicated. Gastrostomy presence (odds ratio (OR) 5.51 (1.96-15.46), P = 0.001), consultant providers (OR 2.69 (1.23-5.87), P = 0.01) and inpatient setting (OR 2.35 (1.16-4.77), P = 0.02) were all associated with a higher likelihood of non-indicated prescribing. The child having a predisposing diagnosis was significantly associated with indicated prescribing (OR 0.41 (0.21-0.80), P = 0.009). A total of 75% of hospital and patient spending was for non-indicated prescriptions. Annual costs of non-indicated AST for Melbourne's RCH were projected to be $15 493., Conclusions: Non-indicated acid-suppression prescribing is common in a tertiary paediatric hospital and associated with gastrostomy presence, consultant providers and inpatient status. Future research should use qualitative methods to understand clinician and patient drivers of prescribing and use this information to develop and test targeted solutions to reduce non-indicated AST prescribing., (© 2018 Paediatrics and Child Health Division (The Royal Australasian College of Physicians).)

All medical and surgical specialties depend on the pool of effective antibiotics that continues to evaporate because of the increasing prevalence of drug-resistant bacteria. Antimicrobial-resistant infections kill 700,000 patients every year. By 2050, they are projected to cause 10 million deaths per year at a cumulative global cost of $100 trillion. Professional societies and international health agencies, including the United Nations, have declared escalating antimicrobial resistance as one of the gravest and most urgent threats to global public health and issued calls for action. The propensity of bacteria to mobilize and share genetic resistance determinants across species and genera, record levels of conflict-driven human population displacement, and the dearth of new antibiotics and rapid diagnostic tests, along with climate change and the epidemic of opioid addiction, exacerbate the antimicrobial resistance crisis. The predominant cause of antibiotic resistance is exposure to antibiotics through appropriate and inappropriate use. Mindfulness, nudging by peers, and adjuncts and alternatives to antibiotics, such as phage therapies, microbiome-based therapies, and novel medical informatics applications, could help reduce antibiotic use. This article describes the antimicrobial resistance crisis and highlights points in the continuum of care in which clinicians can readily implement practical, no-cost changes to minimize antibiotic exposure., (Copyright © 2018 Mayo Foundation for Medical Education and Research. Published by Elsevier Inc. All rights reserved.)

Background: Behavioral economics interventions have been shown to effectively reduce the rates of inappropriate antibiotic prescriptions for acute respiratory infections (ARIs)., Objective: To determine the cost-effectiveness of three behavioral economic interventions designed to reduce inappropriate antibiotic prescriptions for ARIs., Design: Thirty-year Markov model from the US societal perspective with inputs derived from the literature and CDC surveillance data., Subjects: Forty-five-year-old adults with signs and symptoms of ARI presenting to a healthcare provider., Interventions: (1) Provider education on guidelines for the appropriate treatment of ARIs; (2) Suggested Alternatives, which utilizes computerized clinical decision support to suggest non-antibiotic treatment choices in lieu of antibiotics; (3) Accountable Justification, which mandates free-text justification into the patient's electronic health record when antibiotics are prescribed; and (4) Peer Comparison, which sends a periodic email to prescribers about his/her rate of inappropriate antibiotic prescribing relative to clinician colleagues., Main Measures: Discounted costs, quality-adjusted life years (QALYs), and incremental cost-effectiveness ratios., Key Results: Each intervention has lower costs but higher QALYs compared to provider education. Total costs for each intervention were $178.21, $173.22, $172.82, and $172.52, and total QALYs were 14.68, 14.73, 14.74, and 14.74 for the control, Suggested Alternatives, Accountable Justification, and Peer Comparison groups, respectively. Results were most sensitive to the quality-of-life of the uninfected state, and the likelihood and costs for antibiotic-associated adverse events., Conclusions: Behavioral economics interventions can be cost-effective strategies for reducing inappropriate antibiotic prescriptions by reducing healthcare resource utilization.

Introduction: Antibiotics are among the most commonly misused of all drugs, which results in antibiotic resistance and waste of resources and it has not been studied in Ethiopia. Therefore, this study was carried out to assess antibiotic use-related problems and their costs among patients hospitalized at the surgical ward of Jimma University Medical Center., Methods: Hospital-based prospective observational study was used to assess the prevalence, cost, and determinants of antibiotic use-related problems; multiple stepwise backward logistic regression analysis was done for a P value of < 0.25 to look for predictors of antibiotic use-related problems. Written informed consent was obtained and confidentiality was secured., Results: Among 300 participants, antibiotic use-related problems (ABURPs) were found in 69.3% of the study participants. The direct total cost attributed to these problems was approximated to a minimum of 2230.15 US$. Independent predictors for antibiotic use-related problems were: indication for antibiotic use like: use of antibiotic for prophylaxis; p < 0.0001, antibiotic use for both therapeutic & prophylaxis; p < 0.0001, CDC wound class I and II; p = 0.016 and; p = 0.002 respectively, overall poly-pharmacy and greater than 2 antibiotic exposure during hospital stay; p = 0.019and p = 0.006 respectively and hospital stay for ≥21 days; p = 0.007., Conclusion: The prevalence of antibiotic use-related problems was high and resulted in extra cost. Antibiotic use for prophylaxis, prophylaxis, and treatment, poly-pharmacy, greater than 2 antibiotic exposures during the hospital stay, CDC wound class I and II, and duration of hospital stay of ≥ 21 days was found to be independent predictors of antibiotic use-related problems., Competing Interests: The authors have declared that no competing interests exist.

Objectives: To determine the economic impact of three drugs commonly involved in potentially inappropriate prescribing (PIP) in adults aged ≥65 years, including their adverse effects (AEs): long-term use of non-steroidal anti-inflammatory drugs (NSAIDs), benzodiazepines and proton pump inhibitors (PPIs) at maximal dose; to assess cost-effectiveness of potential interventions to reduce PIP of each drug., Design: Cost-utility analysis. We developed Markov models incorporating the AEs of each PIP, populated with published estimates of probabilities, health system costs (in 2014 euro) and utilities., Participants: A hypothetical cohort of 65 year olds analysed over 35 1-year cycles with discounting at 5% per year., Outcome Measures: Incremental cost, quality-adjusted life years (QALYs) and incremental cost-effectiveness ratios with 95% credible intervals (CIs, generated in probabilistic sensitivity analysis) between each PIP and an appropriate alternative strategy. Models were then used to evaluate the cost-effectiveness of potential interventions to reduce PIP for each of the three drug classes., Results: All three PIP drugs and their AEs are associated with greater cost and fewer QALYs compared with alternatives. The largest reduction in QALYs and incremental cost was for benzodiazepines compared with no sedative medication (€3470, 95% CI €2434 to €5001; -0.07 QALYs, 95% CI -0.089 to -0.047), followed by NSAIDs relative to paracetamol (€806, 95% CI €415 and €1346; -0.07 QALYs, 95% CI -0.131 to -0.026), and maximal dose PPIs compared with maintenance dose PPIs (€989, 95% CI -€69 and €2127; -0.01 QALYs, 95% CI -0.029 to 0.003). For interventions to reduce PIP, at a willingness-to-pay of €45 000 per QALY, targeting NSAIDs would be cost-effective up to the highest intervention cost per person of €1971. For benzodiazepine and PPI interventions, the equivalent cost was €1480 and €831, respectively., Conclusions: Long-term benzodiazepine and NSAID prescribing are associated with significantly increased costs and reduced QALYs. Targeting inappropriate NSAID prescribing appears to be the most cost-effective PIP intervention., Competing Interests: Competing interests: None declared., (© 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.)

Aim: To describe disciplinary cases for inappropriate prescribing of drugs of dependence by doctors in New Zealand, 1997-2016., Methods: A retrospective analysis of disciplinary decisions to describe characteristics of cases (setting, drugs, outcome) and doctors (sex, specialty, years since qualification)., Results: There were 25 disciplinary decisions involving 24 doctors. Disciplined doctors were mostly male (19;76%), working in general practice (19;76%), and older (mean 24 years in practice). Pharmacists were the most common source of notification to the authorities (6;24%); medical colleagues reported only four (16%). The alleged misconduct often involved behaviour in addition to inappropriate prescribing. In all cases the doctor was found guilty of professional misconduct. Penalties were severe: six doctors were removed from practice, 11 were suspended, and of the remainder all but one had restrictions on practice imposed. In many decisions there was no patient harm documented., Conclusion: Disciplinary cases for inappropriate prescribing of drugs of dependence by doctors in New Zealand are not common, but the consequences can be dire. The role of discipline in doctors with drug dependence is unclear., Competing Interests: Nil.

We conducted a retrospective study to investigate adverse drug reactions and associated medical costs among elderly individuals that could be avoided if pharmacotherapy was performed in accordance with the Beers Criteria: the Japanese Version (BCJV) and Guidelines for Medical Treatment and Its Safety in the Elderly 2015 (GL2015). Patients aged at least 65 years who were either hospitalized at Gifu Municipal Hospital between October 1 and November 30, 2014 (n = 1236) or had outpatient examinations at Gifu Municipal Hospital on October 1-2, 2014 (n = 980) were included in the study. The outcomes measured were usage rates of drugs listed in the BCJV and GL2015, incidence rates of adverse drug reactions, and additional costs incurred per patient due to adverse reactions. Among the inpatients, usage rates of drugs listed in the BCJV and GL2015 were 24.0 and 72.4%, respectively, and adverse reactions to these drugs occurred at rates of 3.0 and 8.2%, respectively. Among the outpatients, while the usage rates were 26.2% (BCJV) and 59.9% (GL2015), the incidence rates of adverse reactions were 4.7% (BCJV) and 3.9% (GL2015). The additional costs incurred due to adverse drug reactions ranged from 12713-163925 yen per patient. Our results demonstrate that appropriate use of drugs based on the BCJV and GL2015 can help prevent adverse reactions; this would reduce the overall medical costs.

Changes in the pharmacokinetics and pharmacodynamics of drugs in the presence of certain comorbidities and geriatric syndromes and reduced tolerability of potential drug side effects due to physiological changes with aging lead to difficulties in planning treatments in elderly adults, especially patients with dementia. The Comprehensive Geriatric Assessment has an important role in assessing polypharmacy and optimizing potentially inappropriate medications and potentially prescribing omissions in these patients. For this reason, we intend to reexamine our new study titled " Costs of medication in older patients: before and after comprehensive geriatric assessment," because most of these results are also very important for dementia practice.

Pharmaceutical expenditure is a cost item that is monitored continuously, to verify the appropriateness of prescriptions, the good use of available resources and to contain costs. However, socioeconomic differences in the population affect health conditions and consequently health expenditure. A comparison of socio-economic determinants and per-capita pharmaceutical expenditure in the different municipalities of Roma Capitale (Capital city of Rome, Italy) indicates that higher expenditures occur in areas characterized by lower socio-economic conditions.

Background: We developed a multifaceted intervention to reduce antibiotic prescription rate for children with upper respiratory tract infections (URTIs) among primary care doctors in township hospitals in China. The intervention achieved a 29% (95% CI 16-42) absolute risk reduction in antibiotic prescribing. This study was to assess the cost-effectiveness of our intervention at reducing antibiotic prescribing in rural primary care facilities as measured by the intervention's effect on the antibiotic prescription rates for childhood URTIs., Methods: We took a healthcare provider perspective, measuring costs of consultation (time cost of doctor), prescription monitoring process and peer-review meetings (time cost of participants) and medication costs. Costs on provider side were collected through a bespoke questionnaire from all 25 township hospitals in December 2016, while medication costs were collected prospectively in the trial. Incremental cost-effectiveness ratios were calculated by dividing the mean difference in cost of the two trial arms by the mean difference in antibiotic prescribing rate., Results: This showed an incremental cost of $0.03 per percentage point reduction in antibiotic prescribing. In addition to this incremental cost, the cost of implementing the intervention, including training and materials delivered by township hospitals, was $390.65 (SD $145.68) per healthcare facility., Conclusions: This study shows that a multifaceted intervention programme, when embedded into routine practice, is very cost-effective at reducing antibiotic prescribing in primary care facilities and has the potential of scale up in similar resource limited settings., (© 2018 John Wiley & Sons Ltd.)

Objectives: To quantify the costs, benefits and cost-effectiveness of three multipathogen point-of-care (POC) testing strategies for detecting common sexually transmitted infections (STIs) compared with standard laboratory testing., Design: Modelling study., Setting: Genitourinary medicine (GUM) services in England., Population: A hypothetical cohort of 965 988 people, representing the annual number attending GUM services symptomatic of lower genitourinary tract infection., Interventions: The decision tree model considered costs and reimbursement to GUM services associated with diagnosing and managing STIs. Three strategies using hypothetical point-of-care tests (POCTs) were compared with standard care (SC) using laboratory-based testing. The strategies were: A) dual POCT for Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG); B) triplex POCT for CT-NG and Mycoplasma genitalium (MG); C) quadruplex POCT for CT-NG-MG and Trichomonas vaginalis (TV). Data came from published literature and unpublished estimates., Primary and Secondary Outcome Measures: Primary outcomes were total costs and benefits (quality-adjusted life years (QALYs)) for each strategy (2016 GB, £) and associated incremental cost-effectiveness ratios (ICERs) between each of the POC strategies and SC. Secondary outcomes were inappropriate treatment of STIs, onward STI transmission, pelvic inflammatory disease in women, time to cure and total attendances., Results: In the base-case analysis, POC strategy C, a quadruplex POCT, was the most cost-effective relative to the other strategies, with an ICER of £36 585 per QALY gained compared with SC when using microcosting, and cost-savings of £26 451 382 when using tariff costing. POC strategy C also generated the most benefits, with 240 467 fewer clinic attendances, 808 fewer onward STI transmissions and 235 135 averted inappropriate treatments compared with SC., Conclusions: Many benefits can be achieved by using multipathogen POCTs to improve STI diagnosis and management. Further evidence is needed on the underlying prevalence of STIs and SC delivery in the UK to reduce uncertainty in economic analyses., Competing Interests: Competing interests: All authors have completed the Unified Competing Interest Form and declare financial support from Innovate UK; EJA, SEH, MJH are employees of Aquarius Population Health (APH), which reports grants from Innovate UK grant to Atlas Genetics, during the conduct of the study; other from Cepheid, St Georges University of London, Enigma Diagnostics and AstraZeneca, on STI and POC research outside the submitted work; RMB is a Lecturer and Programme Director of Economics at St. Angela’s College Sligo/NUI Galway and an academic staff member of the Health Economics and Policy Analysis Centre (HEPAC) at NUI Galway, providing health economic support to Aquarius Population Health on an ad hoc consultancy basis. STS, EH-E, SSF are members of the Applied Diagnostic Research and Evaluation Unit at St George’s, University of London, which has received funding from Atlas Genetics, Alere, Cepheid, SpeeDx and Sekisui. STS has received NIHR funding to develop a POCT with Atlas., (© Author(s) (or their employer(s)) 2018. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Aims: Polypharmacy is increasingly common in older adults, placing them at risk of medication-related harm (MRH). Patients are particularly vulnerable to problems with their medications in the period following hospital discharge due to medication changes and poor information transfer between hospital and primary care. The aim of the present study was to investigate the incidence, severity, preventability and cost of MRH in older adults in England postdischarge., Methods: An observational, multicentre, prospective cohort study recruited 1280 older adults (median age 82 years) from five teaching hospitals in Southern England, UK. Participants were followed up for 8 weeks by senior pharmacists, using three data sources (hospital readmission review, participant telephone interview and primary care records), to identify MRH and associated health service utilization., Results: Overall, 413 participants (37%) experienced MRH (556 MRH events per 1000 discharges), of which 336 (81%) cases were serious and 214 (52%) potentially preventable. Four participants experienced fatal MRH. The most common MRH events were gastrointestinal (n = 158, 25%) or neurological (n = 111, 18%). The medicine classes associated with the highest risk of MRH were opiates, antibiotics and benzodiazepines. A total of 328 (79%) participants with MRH sought healthcare over the 8-week follow-up. The incidence of MRH-associated hospital readmission was 78 per 1000 discharges. Postdischarge MRH in older adults is estimated to cost the National Health Service £396 million annually, of which £243 million is potentially preventable., Conclusions: MRH is common in older adults following hospital discharge, and results in substantial use of healthcare resources., (© 2018 The Authors. British Journal of Clinical Pharmacology published by John Wiley & Sons Ltd on behalf of British Pharmacological Society.)

Aim: The effects of frailty and multiple chronic conditions (MCCs) on cost of care are rarely disentangled in archival data studies. We identify the marginal contribution of frailty to medical care cost estimates using Medicare data. Materials & methods: Use of the Faurot frailty score to identify differences in acute medical events and cost of care for patients, controlling for MCCs and medication use. Results: Estimated marginal cost of frailty was US$10,690 after controlling for demographics, comorbid conditions, polypharmacy and use of potentially inappropriate medications. Conclusion: Frailty contributes greatly to cost of care, but while often correlated, is not synonymous with MCCs. Thus, it is important to control separately for frailty in studies that compare medical care use and cost.

Background: In the growing population of the elderly, drug-related problems are considered an important health care safety issue. One aspect of this is the prescription of potentially inappropriate medication (PIM) which is considered to increase health care costs., Objective: Using data from the Health Economics of Potentially Inappropriate Medication (HEPIME) study, we aimed to analyze how the number of prescribed substances moderates the association of PIM use as defined by the German PRISCUS list and health care costs applying a longitudinal perspective., Methods: An initial number of 6,849,622 insurants aged 65+ of a large German health insurance company were included in a retrospective matched cohort study. Based on longitudinal claims data from the four separate quarters of a 12-month pre-period, 3,860,842 individuals with no exposure to PIM in 2011 were matched to 508,212 exposed individuals. Exposure effects of PIM use on health care costs and the number of prescribed substances were measured based on longitudinal claims data from the four separate quarters of the 12-month post-period., Results: After successful balancing for the development of numerous matching variables during the four quarters of the pre-period, exposed individuals consumed 2.1 additional prescribed substances and had higher total health care costs of 1,237 € when compared to non-exposed individuals in the 1st quarter of the post-period. Controlling for the number of prescribed substances, the difference in total health care costs between both study groups was 401 €. The average effect of one additionally prescribed substance (other than PIM) on total health care costs was increased by an amount of 137 € for those being exposed to a PIM. In quarters 2-4 of the post-period, the differences between both study groups tended to decrease sequentially., Conclusions: PIM use has an increasing effect on the development of health care costs. This cost-increasing effect of PIM use is moderated by the number of prescribed substances., Competing Interests: The authors have declared that no competing interests exist.

Background: Limited studies have evaluated the effectiveness of pharmacist interventions on outpatient prescription. The goal of this study was to evaluate the clinical and economic impacts of pharmacist interventions on randomly sampled outpatient prescriptions., Method: Outpatient prescriptions of our hospital were sampled automatically and reviewed by pharmacists since 2011. Pharmacists intervened in inappropriate prescriptions (IPs) real-timely, and summarized and analyzed the information monthly. Cost-benefit analysis was performed to estimate the economic benefit of the pharmacist intervention., Results: From 2011 to 2016, pharmacists reviewed 101,271 prescriptions and intervened in 5155 prescriptions. With the interventions of pharmacists, the number of IPs decreased from 1845 to 238, while the inappropriate percentage decreased from 12.60 to 1.22%. The inappropriate rates of different departments and the types decreased annually. IPs were mainly from the Department of Medicine and Department of Surgery and category 1 (Non-indicated medications) in all years. The benefit-to-cost ratios of pharmacist interventions were always more than 1. In the same years, the benefit-to-cost ratios in public payments were higher than those with insurance and self-payment., Conclusion: This form of pharmacist intervention constitutes a method that showed positive clinical and economic benefits and is worth expanding in large hospitals. Pharmacists should pay more attention on prescriptions in department of surgery or prescriptions with public payments.

Background: Polypharmacy and inappropriate drug use cause numerous complications, such as cognitive impairment, frailty, falls, and functional dependence. The present study aimed to determine the effect of the comprehensive geriatric assessment (CGA) on polypharmacy, potentially inappropriate medications (PIMs) and potential prescribing omissions (PPOs), and to evaluate the economic reflections of medication changes., Methods: One thousand five hundred and seventy-nine older patients, who had undergone CGA, were retrospectively evaluated. The drugs, drug groups, and number of drugs that the patients used were recorded. Appropriate drug therapy was identified by both CGA and STOPP/START criteria. Based on these criteria, PIMs were discontinued and PPOs were started. The monthly cost of these drugs was calculated separately for PIMs and PPOs by using the drugstore records., Results: After CGA, while the prevalence of non-polypharmacy was increased from 43.3% to 65.6%, the prevalence of polypharmacy and hyperpolypharmacy was decreased from 56.7% to 34.4% and 12.0% to 3.6%, respectively. The three most common PIMs discontinued were proton pump inhibitors, anti-dementia drugs, and antipsychotics, respectively. However, the most common PPOs started were vitamin D and B12 supplements, and anti-depressants. After CGA, monthly saved total per capita cost of PIMs was US$12.8 and monthly increased total per capita cost of PPOs was $5.6., Conclusion: It was demonstrated that prevalence of polypharmacy, PIM, and PPO could be decreased by CGA including START/STOPP criteria in older adults. Furthermore, this will have beneficial effects on economical parameters due to decreasing drug-related health care costs., Competing Interests: Disclosure The authors report no conflicts of interest in this work.

The high cost of cancer care worldwide is largely attributable to rising drugs prices. Despite their high costs and potential toxic effects, anticancer treatments could be subject to overuse, which is defined as the provision of medical services that are more likely to harm than to benefit a patient. We found 30 studies documenting medication overuse in cancer, which included 16 examples of supportive medication overuse and 17 examples of antineoplastic medication overuse in oncology. Few specific agents have been assessed, and no studies investigated overuse of the most toxic or expensive medications currently used in cancer treatment. Although financial, psychological, or physical harms of medication overuse in cancer could be substantial, there is little published evidence addressing these harms, so their magnitude is unclear. Further research is needed to better quantify medication overuse, understand its implications, and help protect patients and the health-care system from overuse., (Copyright © 2018 Elsevier Ltd. All rights reserved.)

Objective: The effect of total exemption from medical service co-payments on drug prescribing practices has not been extensively evaluated. We conducted a retrospective cross-sectional study to evaluate the effect of total exemption from medical service co-payments on potentially inappropriate medication (PIM) and benzodiazepine use in elderly ambulatory patients. We defined PIM based on the Beers Criteria., Results: Six hundred seventy-one consecutive patients aged 65 years or older who routinely visited internal medicine physicians were included. Their mean age was 75.7 years, and 342 (51.0%) patients were men. The proportions of patients taking any PIMs or benzodiazepines were 37.7% and 16.2%, respectively. Of all patients, 62 (9.2%) were totally exempt from medical service co-payments. The patients who were totally exempt from medical service co-payments showed a significantly increased risk of PIM (OR 2.16, 95% CI 1.28-3.66) or benzodiazepine use (OR 2.12, 95% CI 1.16-3.87) compared with patients who were not. These associations did not change after adjusting for age, gender, comorbidities and polypharmacy. These findings should be confirmed in other settings or hospitals in Japan.

Background: The potential harms of some medications may outweigh their potential benefits (inappropriate medication use). Despite recommendations to avoid the use of potentially inappropriate medications (PIMs) in older adults, the prevalence of PIM use is high in different settings including residential aged care. However, it remains unclear what the costs of these medications are in this setting. The main objective of this study was to determine the costs of PIMs in older adults living in residential care. A secondary objective was to examine if there was a difference in costs of PIMs in a home-like model of residential care compared to an Australian standard model of care., Methods: Participants included 541 participants from the Investigation Services Provided in the Residential Environment for Dementia (INSPIRED) Study. The INSPIRED study is a cross-sectional study of 17 residential aged care facilities in Australia. 12 month medication costs were determined for the participants and PIMs were identified using the 2015 updated Beers Criteria for older adults., Results: Of all of the medications dispensed in 1 year, 15.9% were PIMs and 81.4% of the participants had been exposed to a PIM. Log-linear models showed exposure to a PIM was associated with higher total medication costs (Adjusted β = 0.307, 95% CI 0.235 to 0.379, p < 0.001). The mean proportion (±SD) of medication costs that were spent on PIMs in 1 year was 17.5% (±17.8) (AUD$410.89 ± 479.45 per participant exposed to a PIM). The largest PIM costs arose from proton-pump inhibitors (34.4%), antipsychotics (21.0%) and benzodiazepines (18.7%). The odds of incurring costs from PIMs were 52% lower for those residing in a home-like model of care compared to a standard model of care., Conclusions: The use of PIMs for older adults in residential care facilities is high and these medications represent a substantial cost which has the potential to be lowered. Further research should investigate whether medication reviews in this population could lead to potential cost savings and improvement in clinical outcomes. Adopting a home-like model of residential care may be associated with reduced prevalence and costs of PIMs.

Aim: This study aims to determine the prevalence of potentially inappropriate prescribing (PIP) among patients discharged from Internal Medicine, the drugs and factors associated and economic cost of PIP., Methods: This retrospective cross-sectional, single-center study included participants aged ≥65 years consecutively discharged from the Internal Medicine Unit in a tertiary hospital of Southern Spain. PIP was defined by the Screening Tool for Older Persons Prescriptions (STOPP-2) criteria version 2 (2015 update). The association of PIP with chronic conditions was analyzed using multilevel logistic regression model. Data on economic cost associated to PIP were determined according to the computerized prescribing database of Andalusia ("Receta XXI")., Results: Out of the 275 patients studied, a total of 249 PIPs were detected in 114 (41.5%) patients of whom 79 (28.7%) had one or two STOPP-2 criteria and 35 (12.7%) 3 or more criteria. The most involved drugs were benzodiazepines (45.5%); antithrombotics (14.5%), including anticoagulants or antiplatelets, and opioids (11.4%). The multivariate logistic regression analysis identified polypharmacy (OR=11.00; 95% CI 1.41-85.52) and extreme polypharmacy (OR=26.25; 95% CI 3.34-206.07) as independent risk factors for PIP. The mean cost of PIP was €18.75±4.24 per patient and month. Opioids accounted for the highest percentage expenditure of PIP (39.02%), followed by inhaled bronchodilator drugs (30.30%), antithrombotics (12.20%) and benzodiazepines (7.92%)., Conclusions: PIP is frequent among patients discharged from Internal Medicine. The number of prescribed drugs was independently associated to PIP and benzodiazepines were the most involved drugs. PIP was associated to a significant economic cost., (Copyright © 2017 Elsevier B.V. All rights reserved.)

Stress ulcer prophylaxis (SUP) is often inappropriately utilized, particularly in critically ill patients. The objective of this study is to find an effective way of reducing inappropriate SUP use in an academic medical intensive care unit (ICU). Medical ICU patients receiving SUP were identified over a 1-month period, and their charts were reviewed to determine whether American Society of Health-System Pharmacists guidelines were followed. Inappropriate usage was calculated as inappropriate patient-days and converted to incidence per 100 patient-days. Two interventions were implemented: (1) Pharmacists reviewed indications for SUP on each patient during daily team rounds and daily medication reconciliation and (2) residents rotating on ICU services were educated on a bimonthly basis. Postintervention data were obtained in a similar fashion. Prior to intervention, the incidence of inappropriate SUP usage was calculated to be 26.75 per 100 patient-days (n = 1099 total patient-days). Total cost attributable to the inappropriate use was $2433. Post intervention, we were able to decrease the inappropriate incidence of SUP usage to 7.14 per 100 patient-days (n = 1149 total patient-days). In addition, total cost of inappropriate use was reduced to $239.80. Our study highlights an effective multidisciplinary approach to reduce the inappropriate use of SUP in an academic medical ICU. We were able to reduce the incidence of inappropriate use of SUP by 73.31% ( P < .001). Furthermore, we were able to decrease the costs by approximately $2200/month.

Objective: To update a past systematic review on whether Medicare Part D changed drug utilization and out-of-pocket (OOP) costs overall and within subpopulations, and to identify evidence gaps., Data Sources/study Setting: Published and gray literature from 2010 to 2015 meeting prespecified screening criteria, including having a comparison group, and utilization or OOP cost outcomes., Study Design: We conducted a systematic literature review with a quality assessment., Data Collection/extraction Methods: For each study, we extracted information on study design, data sources, analytic methods, outcomes, and limitations. Because outcome measures vary across studies, we did a qualitative synthesis rather than meta-analysis., Principal Findings: Sixty-five studies met screening criteria. Overall, Medicare Part D enrollees have increased drug utilization and decreased OOP costs, but coverage gaps limit the program's impact. Beneficiaries whose insurance becomes more generous after enrollment had disproportionately increased drug utilization and decreased OOP costs. Outcomes among dual-eligibles were mixed., Conclusions: There is strong evidence on how Medicare Part D and the donut hole coverage gap affect utilization and OOP costs, but weak evidence on how effects vary among dual-eligibles or across diseases. Findings suggest that the Affordable Care Act's provisions to expand coverage and reduce the donut hole should improve patient outcomes., (© Health Research and Educational Trust.)