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Antibacterianos , Médicos Generales , Pautas de la Práctica en Medicina , Humanos , Antibacterianos/uso terapéutico , Antibacterianos/administración & dosificación , Pautas de la Práctica en Medicina/normas , Retroalimentación , Prescripciones de Medicamentos/normas , Prescripción Inadecuada/prevención & controlRESUMEN
PURPOSE: Malnutrition is common in children with cancer. While multiple validated malnutrition screens exist, there is no universal, standardized approach to screen or diagnose malnutrition. The Multinational Association of Supportive Care in Cancer (MASCC) Pediatric Study Group is focused on oncologic supportive care for children and young adults. This subgroup designed and administered a pilot study to characterize global malnutrition screening, diagnosis, and treatment practices for pediatric patients with cancer after identifying variations in malnutrition practice patterns within its members. METHODS: A novel, exploratory survey was iteratively developed and distributed in early 2020 to 45 MASCC Pediatric Study Group members. The survey included multiple questions with standard patient presentations and nutritional scenarios, and the respondents selected the answer that best reflected the care patients would receive at their institution. RESULTS: A validated screening tool to assess for malnutrition was routinely used by 15 of 26 respondents (58%). No single validated screen was used by more than 24% of responders, and 11 of 26 (42%) reported not having a standard malnutrition treatment screen. When the same patient was presented with the survey using different malnutrition indicators, patient care plans varied greatly. This was particularly true for z-scores compared to weight percentiles. CONCLUSIONS: Development of consensus recommendations for screening practices, preferred malnutrition indicators, and treatment guidelines could help reduce the underdiagnosis of malnutrition and subsequent variation in its management and ought to be a focus of the global pediatric cancer supportive care community.
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Desnutrición , Neoplasias , Apoyo Nutricional , Humanos , Neoplasias/complicaciones , Neoplasias/terapia , Niño , Desnutrición/diagnóstico , Desnutrición/terapia , Desnutrición/etiología , Proyectos Piloto , Apoyo Nutricional/métodos , Encuestas y Cuestionarios , Evaluación Nutricional , Adolescente , Masculino , Pautas de la Práctica en Medicina/estadística & datos numéricos , Pautas de la Práctica en Medicina/normas , FemeninoRESUMEN
BACKGROUND: Direct oral anticoagulants (DOACs) have complex dosing regimens and are often incorrectly prescribed. We evaluated a nationwide DOAC population management dashboard rollout whose purpose includes pharmacist review and correction of off-label dosing prescriptions. METHODS AND RESULTS: Using data from Veterans Health Affairs, we identified all patients prescribed DOACs for atrial fibrillation or venous thromboembolism between August 2015 and December 2019. Sites were grouped on the basis of the timing of moderate-high usage of the DOAC population management tool dashboard. Effectiveness was defined as the monthly rate of off-label DOAC prescribing and the rate of clinical adverse events (bleeding, composite of stroke or venous thromboembolism). Implementation was evaluated as the percentage of off-label DOAC prescriptions changed within 7 days. Among the 128 652 patients receiving DOAC therapy at 123 centers, between 6.9% and 8.6% had off-label DOAC prescriptions. Adoption of the DOAC population management tool dashboard before July 2018 was associated with a decline in off-label dosing prescriptions (8.7%-7.6%). Only 1 group demonstrated a significant reduction in monthly rates of bleeding following implementation. All sites experienced a reduction in the composite of venous thromboembolism or stroke following dashboard adoption. There was no difference in the implementation outcome of DOAC prescription change within 7 days in any of the adoption groups. CONCLUSIONS: Early adoption of the DOAC population management tool dashboard was associated with decreased rates of off-label DOAC dosing prescription and reduced bleeding. Following adoption of the DOAC population management tool dashboard, all sites experienced reductions in venous thromboembolism and stroke events.
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Fibrilación Atrial , Uso Fuera de lo Indicado , Farmacéuticos , Tromboembolia Venosa , Humanos , Fibrilación Atrial/tratamiento farmacológico , Fibrilación Atrial/complicaciones , Estados Unidos , Tromboembolia Venosa/tratamiento farmacológico , Tromboembolia Venosa/prevención & control , Tromboembolia Venosa/epidemiología , Femenino , Masculino , Anciano , Hemorragia/inducido químicamente , Hemorragia/epidemiología , Accidente Cerebrovascular/prevención & control , Accidente Cerebrovascular/epidemiología , Administración Oral , Anticoagulantes/efectos adversos , Anticoagulantes/administración & dosificación , Anticoagulantes/uso terapéutico , Inhibidores del Factor Xa/efectos adversos , Inhibidores del Factor Xa/uso terapéutico , Inhibidores del Factor Xa/administración & dosificación , Pautas de la Práctica en Medicina/normas , Prescripciones de Medicamentos/estadística & datos numéricos , United States Department of Veterans AffairsRESUMEN
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 ß-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.
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Antibacterianos , Programas de Optimización del Uso de los Antimicrobianos , Adhesión a Directriz , Pautas de la Práctica en Medicina , Centros de Atención Terciaria , Humanos , Antibacterianos/uso terapéutico , Laos/epidemiología , Femenino , Masculino , Adulto , Persona de Mediana Edad , Centros de Atención Terciaria/estadística & datos numéricos , Prevalencia , Pautas de la Práctica en Medicina/estadística & datos numéricos , Pautas de la Práctica en Medicina/normas , Adhesión a Directriz/estadística & datos numéricos , Adolescente , Adulto Joven , Niño , Anciano , Encuestas y Cuestionarios , Prescripciones de Medicamentos/estadística & datos numéricos , Prescripciones de Medicamentos/normas , Preescolar , Indicadores de Calidad de la Atención de Salud , Lactante , Estudios TransversalesRESUMEN
IMPORTANCE: Despite evidence that most upper respiratory infections (URIs) are due to viruses, antibiotics are frequently prescribed for this indication in the outpatient setting. Antibiotic stewardship strategies are needed to reduce adverse patient outcomes and staggering healthcare costs due to resistant infections that ensue from inappropriate prescriptions. OBJECTIVE: To determine if individual provider scorecards detailing antibiotic prescribing rates paired with educational resources reduce inappropriate antibiotic use for URIs in the outpatient primary care setting. DESIGN, SETTING AND PARTICIPANTS: This quality improvement project investigated the number of URI-coded office visits in the primary care setting over three consecutive influenza seasons, which resulted in an antibiotic prescription in Cooper University Healthcare's 14 primary care offices. We compared provider's individual prescribing patterns to their peers' average and created a scorecard that was shared with each provider over a series of intervention phases. Data were collected from a preintervention period (November 2017-February 2018), and two postintervention phases, phase I (November 2018-February 2019) and phase II (November 2019-February 2020). INTERVENTION: A personalised, digital scorecard containing antibiotic-prescribing data for URI-coded visits from the prior influenza season was emailed to each primary care provider. Prior to the subsequent influenza season, prescribers received their updated prescribing rates as well as peer-to-peer comparisons. In both phases, the scorecard was attached to an email with antimicrobial stewardship educational materials. MAIN OUTCOMES AND MEASURES: The primary outcome was a reduction in the number of inappropriate antibiotic prescriptions for URI-related diagnoses. The diagnoses were organised into five broad coding categories, including bronchitis, sinusitis, sore throat excluding strep, influenza and tonsillitis excluding strep.
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Antibacterianos , Atención Primaria de Salud , Mejoramiento de la Calidad , Infecciones del Sistema Respiratorio , Humanos , Antibacterianos/uso terapéutico , Infecciones del Sistema Respiratorio/tratamiento farmacológico , Atención Primaria de Salud/estadística & datos numéricos , Atención Primaria de Salud/normas , Adulto , Pautas de la Práctica en Medicina/estadística & datos numéricos , Pautas de la Práctica en Medicina/normas , Femenino , Programas de Optimización del Uso de los Antimicrobianos/métodos , Programas de Optimización del Uso de los Antimicrobianos/estadística & datos numéricos , Masculino , Prescripción Inadecuada/estadística & datos numéricos , Prescripción Inadecuada/prevención & control , Persona de Mediana EdadRESUMEN
BACKGROUND: Older people (i.e. ≥40 years) with intellectual disability have unique medication needs and may experience high levels of potentially inappropriate prescribing. Despite the availability of tools to optimize older adults' prescriptions, there is no comprehensive tool specifically for use in older adults with intellectual disability. We aimed to develop a tool for this purpose: Optimizing Pharmaco-Therapy and Improving Medication for Ageing with Intellectual Disability (OPTIMA-ID). RESEARCH DESIGN AND METHODS: A draft tool was developed based on literature review and clinical expertise. Focus groups with healthcare professionals and people with intellectual disability were conducted to refine the tool. The tool was presented electronically to an expert panel for Delphi validation. Median level of agreement and 75th percentile values were used to establish if consensus was reached. Criteria were accepted, rejected, revised or removed to develop the final tool. RESULTS: Following two Delphi rounds, consensus on the content of OPTIMA-ID was reached for 67 prescribing criteria, 63 of which were agreed upon after Round 1 and a further 4 criteria accepted after Round 2. CONCLUSIONS: OPTIMA-ID contains 67 criteria that can optimize medications for older people with intellectual disability. Its effectiveness, feasibility and impact on patient outcomes need to be established.
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Técnica Delphi , Prescripción Inadecuada , Discapacidad Intelectual , Humanos , Discapacidad Intelectual/tratamiento farmacológico , Anciano , Prescripción Inadecuada/prevención & control , Adulto , Grupos Focales , Consenso , Pautas de la Práctica en Medicina/normas , Envejecimiento/fisiología , Persona de Mediana EdadRESUMEN
Appropriate use criteria (AUC) aim to impact the provision of high-value care. This scoping review identified AUC regarding the procedural and operative treatment of cardiovascular disease and described the evolution of AUC in this space over time, including changes in the focus, strategy, and language of AUC. The summative presentation of these AUC identifies elements of AUC that may lead to successes in, and barriers to, implementation across disease processes, specialties, and societies. AUC topics include coronary artery disease, peripheral artery disease, valvular disease, venous disease, renal artery stenosis, and mesenteric ischemia, among others.
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Enfermedades Cardiovasculares , Humanos , Enfermedades Cardiovasculares/terapia , Enfermedades Cardiovasculares/diagnóstico , Adhesión a Directriz/normas , Guías de Práctica Clínica como Asunto , Pautas de la Práctica en Medicina/normas , Factores de Tiempo , Resultado del Tratamiento , Procedimientos Quirúrgicos Vasculares/normasRESUMEN
Intermittent claudication (IC) is a phenotype of peripheral artery disease that is characterized by pain in the lower extremity muscles during activity that is relieved by rest. Medical management, risk factor control, smoking cessation, and exercise therapy have historically been the mainstays of treatment for IC, but advances in endovascular technology have led to increasing use of peripheral vascular interventions in this patient population. There are meaningful differences in published society guidelines and appropriate use criteria relevant to the management of IC, especially regarding indications for peripheral vascular interventions. The current review aims to highlight similarities and differences between major society recommendations for the management of IC, and to discuss practice trends, disparities, and evidence gaps in the use of peripheral vascular interventions for IC in the context of existing guidelines.
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Claudicación Intermitente , Guías de Práctica Clínica como Asunto , Procedimientos Quirúrgicos Vasculares , Humanos , Procedimientos Endovasculares/efectos adversos , Procedimientos Endovasculares/normas , Europa (Continente) , Medicina Basada en la Evidencia/normas , Disparidades en Atención de Salud/normas , Claudicación Intermitente/fisiopatología , Claudicación Intermitente/terapia , Claudicación Intermitente/diagnóstico , Claudicación Intermitente/cirugía , Guías de Práctica Clínica como Asunto/normas , Pautas de la Práctica en Medicina/normas , Factores de Riesgo , Sociedades Médicas/normas , Resultado del Tratamiento , Estados Unidos , Procedimientos Quirúrgicos Vasculares/normas , Procedimientos Quirúrgicos Vasculares/efectos adversosRESUMEN
BACKGROUND: The curricula of Ayurveda programmes emphasise various theoretical constructs such as Tridosha (three factors determining the state of health), Agnibala (digestive strength), Samprapti (patho-physiology), among others. It is often argued that practitioners follow an individualised approach based on these principles while treating patients. Yet, dependable data on their real-world influence is lacking. The aim of this study was to record the extent to which these constructs drive decision-making among Ayurveda practitioners and to examine whether these constructs determine individualisation of the interventions. METHODS: We employed an emailed survey to record physicians' perceptions. Convenience sampling was chosen as the sampling method. Registered Ayurveda practitioners located across India with a minimum of five years of clinical experience were invited to participate. Five case-based scenarios depicting different clinical conditions were presented to the physicians. Questions that accompanied each case scenario asked the physicians to record clinical diagnoses, treatment plans, and the Ayurveda principles that determined their treatment. RESULTS: A total of 141 physicians responded, from whom we received 152 responses as seven physicians responded to more than one scenario. The results suggest a significant lack of consensus among physicians regarding clinical diagnoses, interventions, and their understanding of pathophysiology in the given clinical scenarios. Many conflicting opinions were also noted. CONCLUSION: Theoretical constructs do not appear to determine either prescriptions or individualisation uniformly. Two ethical questions arise: "Is this situation due to an inherently weak theoretical framework of Ayurveda?" and "How can one justify spending hundreds of hours teaching these theories?"
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Medicina Ayurvédica , Médicos , Humanos , India , Médicos/normas , Masculino , Femenino , Actitud del Personal de Salud , Encuestas y Cuestionarios , Medicina de Precisión/normas , Pautas de la Práctica en Medicina/normas , Pautas de la Práctica en Medicina/ética , Adulto , Toma de Decisiones , Persona de Mediana EdadRESUMEN
BACKGROUND: Chronic kidney disease (CKD) is commonly managed in general practice, with established guidelines for diagnosis and management. CKD is more prevalent in the older population, and is associated with lifestyle diseases as well as social deprivation. Older patients also commonly experience multimorbidity. Current CKD guidelines do not take age into account, with the same diagnostic and management recommendations for patients regardless of their age. We sought to investigate general practitioners' (GPs') approach to older patients with CKD, and whether their assessment and management differed from guideline recommendations. We explored the reasons for variation from guideline recommendations. METHODS: This was a mixed methods study of Australian GPs. An online anonymous survey about the use of CKD guidelines, and assessment and management of CKD was sent to 9500 GPs. Four hundred and sixty-nine (5%) of GPs responded, and the survey was completed by 399 GPs. Subsequently, 27 GPs were interviewed in detail about their diagnostic and management approach to older patients with declining kidney function. RESULTS: In the survey, 48% of GPs who responded found the CKD guidelines useful for diagnosis and management. Four themes arose from our interviews: age-related decline in kidney function; whole person care; patient-centred care; and process of care that highlighted the importance of continuity of care. GPs recognised that older patients have an inherently high risk of lower kidney function. The GPs reported management of that higher risk focused on managing the whole person (not just a single disease focus) and being patient-centred. Patient-centred care expressed the importance of quality of life, shared decision making and being symptom focused. There was also a recognition that there is a difference between a sudden decline in kidney function and a stable but low kidney function and GPs would manage these situations differently. CONCLUSIONS: GPs apply guidelines in the management of CKD in older patients using a patient-centred and whole person approach to care. Older patients have a high prevalence of multimorbidity, which GPs carefully considered when applying existing CKD-specific guidelines. Future iterations of CKD Guidelines need to give due consideration to multimorbidity in older patients that can adversely impact on kidney function in addition to the expected age-related functional decline.
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Médicos Generales , Pautas de la Práctica en Medicina , Insuficiencia Renal Crónica , Humanos , Insuficiencia Renal Crónica/terapia , Insuficiencia Renal Crónica/diagnóstico , Insuficiencia Renal Crónica/epidemiología , Masculino , Femenino , Anciano , Australia/epidemiología , Pautas de la Práctica en Medicina/normas , Guías de Práctica Clínica como Asunto , Persona de Mediana Edad , Atención Dirigida al Paciente , Encuestas y Cuestionarios , Adhesión a Directriz , AdultoRESUMEN
PURPOSE: The purpose of this study is to evaluate the pattern, appropriateness, and cost of antidiabetic drugs prescribed for patients with Type 2 diabetes at primary healthcare facilities (PHFs) in China. METHODS: We collected outpatient-visit prescriptions from 363 PHFs in 31 cities covering eastern, central, and western regions of China. The visits of adult patients with Type 2 diabetes diagnosis were collected and classified the antidiabetic medication pattern of each patient use as recommended or non-recommended according to Chinese guidelines. We then calculated the proportion of guideline-recommended patterns and the average monthly cost for each pattern, overall and by region. RESULTS: Of 33 519 prescriptions for Type 2 diabetes, most (73.9%) were for guideline-recommended antidiabetic treatments. The proportion of guideline-recommended prescriptions varied by region (eastern [75.9%], central [87.5%], and western [59.7%]). Metformin monotherapy was the most common guideline-recommended treatment in all three regions (eastern [20.1%], central [28.0%], and western [24.6%]). The most common non-guideline-recommended treatments were monotherapy of insulin (eastern [16.5%], central [5.1%], and western [25.7%]) and traditional Chinese antidiabetic medicines (eastern [5.6%], central [5.7%], and western [11.1%]). The average monthly costs were lower for guideline-recommended treatments compared to non-recommended treatments in all regions (eastern [13.6 ± 15.4 USD vs. 28.1 ± 22.0 USD], central [9.8 ± 10.9 USD vs. 28.7 ± 19.4 USD], and western [17.9 ± 21.4 USD vs. 30.3 ± 23.6 USD]). CONCLUSIONS: The majority of patients with Type 2 diabetes received guideline-recommended antidiabetic medications at PHFs in China, with only half of the prescriptions containing guideline-recommended metformin. Utilization of guideline-recommended therapies differed across regions. Tailored interventions to promote evidence-based antidiabetic prescribing are urgently needed, especially in the undeveloped western region.
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Diabetes Mellitus Tipo 2 , Hipoglucemiantes , Guías de Práctica Clínica como Asunto , Pautas de la Práctica en Medicina , Atención Primaria de Salud , Humanos , Diabetes Mellitus Tipo 2/tratamiento farmacológico , Hipoglucemiantes/uso terapéutico , Hipoglucemiantes/economía , China , Atención Primaria de Salud/estadística & datos numéricos , Pautas de la Práctica en Medicina/estadística & datos numéricos , Pautas de la Práctica en Medicina/normas , Persona de Mediana Edad , Masculino , Femenino , Anciano , Adhesión a Directriz/estadística & datos numéricos , Adulto , Costos de los Medicamentos , Metformina/uso terapéutico , Prescripciones de Medicamentos/estadística & datos numéricosRESUMEN
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 χ2 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.
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Pautas de la Práctica en Medicina , Humanos , Estudios Transversales , Administración Oral , Estudios Retrospectivos , Preescolar , Niño , Masculino , Femenino , Pautas de la Práctica en Medicina/normas , Pautas de la Práctica en Medicina/estadística & datos numéricos , Lactante , Formas de Dosificación , Prescripciones de Medicamentos/estadística & datos numéricos , Prescripciones de Medicamentos/normas , AdolescenteAsunto(s)
Adhesión a Directriz , Hipertensión , Guías de Práctica Clínica como Asunto , Humanos , Hipertensión/tratamiento farmacológico , Adhesión a Directriz/estadística & datos numéricos , Femenino , Masculino , Persona de Mediana Edad , Pautas de la Práctica en Medicina/normas , Pautas de la Práctica en Medicina/estadística & datos numéricos , Antihipertensivos/uso terapéutico , Médicos/psicología , Médicos/normas , Anciano , AdultoRESUMEN
PURPOSE: Neither the United States nor the European oncology guidelines include details for appropriate management of hyperglycemia in cancer patients. The aim was to identify fasting and random blood glucose thresholds, and hemoglobin A1c (HbA1c) targets used by oncologists in clinical practice when managing hyperglycemia in patients with cancer undergoing chemotherapy. METHODS: This national, cross sectional study utilized a questionnaire to collect oncologists' perceptions about optimal blood glucose thresholds and HbA1c targets in patients with cancer undergoing chemotherapy. Descriptive statistics were calculated to summarize glucose thresholds, HbA1c targets, and sample characteristics. Responses to an open-ended question about oncologists' approach to hyperglycemia management were analyzed via thematic analysis using an inductive approach. RESULTS: Respondents (n = 229) were on average 52.1 years of age, 67.7% men, and 91.3% White. For patients without diabetes but experiencing hyperglycemia, oncologists targeted lower and upper fasting blood glucose levels between 75-121 mg/dL and 105-135 mg/dL, respectively. For patients with diabetes, the targets for lower and upper fasting blood glucose levels ranged between 100-130 mg/dL and 128-150 mg/dL, respectively. Fasting blood glucose (95.6%) and HbA1c (78.6%) were the most commonly used clinical indicators to consider chemotherapy dose reduction, delay, or discontinuation due to hyperglycemia in patients receiving chemotherapy with curative intent. Among those receiving palliative intent chemotherapy, the preferred clinical parameters were random blood glucose (90.0%), patient-reported blood glucose readings (70.7%), continuous glucose monitoring readings (65.1%), and patient-reported symptoms of hyperglycemia (65.1%). Three main themes emerged about oncologists' approach to hyperglycemia management: 1) identification of high-risk patients; 2) need for early identification, screening, and diagnosis of hyperglycemia; and 3) multiple hyperglycemia management strategies. CONCLUSION: Oncologists reported a wide variation of target blood glucose ranges considered appropriate in patients undergoing chemotherapy. Lack of clear guidance for hyperglycemia management during chemotherapy in the United States may be contributing to a lack of consistency in clinical practice.
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Antineoplásicos , Glucemia , Hemoglobina Glucada , Hiperglucemia , Neoplasias , Oncólogos , Pautas de la Práctica en Medicina , Humanos , Estudios Transversales , Hiperglucemia/inducido químicamente , Masculino , Femenino , Persona de Mediana Edad , Glucemia/análisis , Glucemia/efectos de los fármacos , Hemoglobina Glucada/análisis , Pautas de la Práctica en Medicina/estadística & datos numéricos , Pautas de la Práctica en Medicina/normas , Neoplasias/tratamiento farmacológico , Encuestas y Cuestionarios , Antineoplásicos/efectos adversos , Antineoplásicos/uso terapéutico , Adulto , Anciano , Estados UnidosRESUMEN
INTRODUCTION: Clinical practice guidelines (CPGs) and clinical recommendations (CRs) are developed to aide and guide providers in treating a variety of conditions, including traumatic brain injury (TBI). There is little knowledge on the impact that CPGs and CRs have on provider practice. One TBI recommendation that was able to be tracked in medical record codes was the use of benzodiazepines (BZD). Because of potential for misuse, diversion, addiction, cognitive impairment, and brain healing interference, the DoD and Department of Veterans Affairs (VA) jointly discourage prescribing BZD after TBI. As part of an effort to look at translation of CPG guidance into clinical practice, our objective was to examine the issuance of BZD prescriptions, including dose, type, and prescribing provider, prescribing setting, and primary diagnosis at issuance among U.S. service members with mild Traumatic Brian Injury (mTBI). MATERIALS AND METHODS: Using DoD data sourced from the Comprehensive Ambulatory/Professional Encounter Record (CAPER) databases of the Military Health System (MHS) Medical Data Repository (MDR), we identified all U.S. service members with a first lifetime diagnosis of mTBI from October 1, 2015 to September 30, 2016. Data on prescriptions issued to this group during a period of active treatment for a mTBI were obtained from the Pharmacy Detail Transaction Service (PDTS) databases of the MDR and identified BZD prescriptions based on the American Hospital Formulary Service (AHFS) therapeutic classification system. We validated coding assumptions through structured review of the clinical record contained within the Armed Forces Health Longitudinal Technology Application (AHLTA) of 30 randomly selected cohort members. RESULTS: Among U.S. service members, 4.5% filled a BZD prescription while under active medical treatment for a recent mTBI. These service members were more likely female and older when compared to their counterparts not prescribed BZD. Among service members under active treatment for mTBI during the study period, 52.6% (n = 7,935) filled a prescription; of these, 8.5% (n = 676) filled a BZD prescription. Of U.S. service members filing a BZD prescription while undergoing active treatment for an mTBI, 64.6% (n = 437) filled prescriptions for BZD and antidepressants, 54.9% (n = 371) filled prescriptions for both BZD and NSAIDS, and 42.2% (n = 285) concurrently filled prescriptions for BZD and opioids. CONCLUSIONS: This effort to examine the translation of CPG recommendations into practice through evaluation of medical record data indicates that providers are prescribing BZD to patients under active treatment for an acute mTBI. The mTBI CPG recommends that the BZD class of medications be avoided in patients healing from brain injury. However, the team recognizes there are confounding factors that may impact the medications that are prescribed for patients with mTBI. Additional work to understand how CPGs and CRs are received and utilized by providers may elucidate opportunities to close the gap between clinical practice guidance and clinical practice.
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Benzodiazepinas , Personal Militar , Humanos , Benzodiazepinas/uso terapéutico , Personal Militar/estadística & datos numéricos , Femenino , Estados Unidos , Adulto , Masculino , Persona de Mediana Edad , Pautas de la Práctica en Medicina/estadística & datos numéricos , Pautas de la Práctica en Medicina/normas , Conmoción Encefálica/tratamiento farmacológico , Conmoción Encefálica/complicacionesRESUMEN
PURPOSE: This study aimed to identify clinical guidelines that provide recommendations on prescribing refractive error correction in children, evaluate the overall quality of these guidelines using the Appraisal of Guidelines for REsearch and Evaluation II (AGREE II) tool and subsequently gain consensus on the prescribing recommendations from high-quality guidelines using the modified Delphi technique. METHODS: A comprehensive search for prescribing guidelines was conducted using databases and professional websites. The quality appraisal of eligible guidelines was undertaken by scoring the six AGREE II domains. Subsequently, the modified Delphi technique was used by 10 experts (sub-specialist optometrists, ophthalmologists and orthoptists) to gain consensus on the prescribing recommendation statements extracted from guidelines that had been identified as high quality. Three rounds were conducted in which agreement of these statements were scored using a 9-point Likert scale with a free-text option for any additional comments. RESULTS: Five eligible guidelines were identified. The AGREE II tool demonstrated that the guidelines varied substantially in quality, with only one guideline identified as being of high quality. A total of 168 prescribing statements were reviewed in the Delphi procedure. Of these, 95 statements reached expert consensus as being appropriate prescribing recommendations. CONCLUSION: There is significant scope for improving current guidelines for prescribing refractive error correction in children. We used the modified Delphi technique to find points of agreement on prescribing recommendations to support professionals prescribing refractive error correction in children. We recommend that further work is needed to address gaps in the guidelines.
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Técnica Delphi , Anteojos , Guías de Práctica Clínica como Asunto , Prescripciones , Errores de Refracción , Humanos , Niño , Prescripciones/normas , Errores de Refracción/terapia , Consenso , Optometría/normas , Pautas de la Práctica en Medicina/normas , Pautas de la Práctica en Medicina/estadística & datos numéricosRESUMEN
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.
Asunto(s)
Médicos Generales , Pautas de la Práctica en Medicina , Humanos , Pautas de la Práctica en Medicina/estadística & datos numéricos , Pautas de la Práctica en Medicina/normas , Australia , Masculino , Médicos Generales/estadística & datos numéricos , Femenino , Persona de Mediana Edad , Adulto , Anciano , Toma de Decisiones , Benzodiazepinas/uso terapéutico , Toma de Decisiones Clínicas/métodos , Antibacterianos/uso terapéutico , Fatiga/tratamiento farmacológico , Prescripciones de Medicamentos/estadística & datos numéricos , Prescripciones de Medicamentos/normasRESUMEN
OBJECTIVES: Most patients with pancreatic cancer who have undergone surgical resection eventually develop disease recurrence. |This study aimed to investigate whether there is evidence to support routine surveillance after pancreatic cancer surgery, with a secondary aim of analyzing the implementation of surveillance strategies in the Nordic countries. MATERIALS AND METHODS: A scoping review was conducted to identify clinical practice guidelines globally and research studies relating to surveillance after pancreatic cancer resection. This was followed by a survey among 20 pancreatic units from four Nordic countries to assess their current practice of follow-up for operated patients. RESULTS: Altogether 16 clinical practice guidelines and 17 research studies were included. The guidelines provided inconsistent recommendations regarding postoperative surveillance of pancreatic cancer. The clinical research data were mainly based on retrospective cohort studies with low level of evidence and lead-time bias was not addressed. Active surveillance was recommended in Sweden and Denmark, but not in Norway beyond the post-operative/adjuvant period. Finland had no national recommendations for surveillance. The Nordic survey revealed a wide variation in reported practice among the different units. About 75% (15 of 20 units) performed routine postoperative surveillance. Routine CA 19-9 testing was used by 80% and routine CT by 67% as part of surveillance. About 73% of centers continued follow-up until 5 years postoperatively. CONCLUSION: Evidence for routine long-term (i.e. 5 years) surveillance after pancreatic cancer surgery remains limited. Most pancreatic units in the Nordic countries conduct regular follow-up, but protocols vary.
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Neoplasias Pancreáticas , Guías de Práctica Clínica como Asunto , Humanos , Neoplasias Pancreáticas/cirugía , Países Escandinavos y Nórdicos , Recurrencia Local de Neoplasia , Pautas de la Práctica en Medicina/estadística & datos numéricos , Pautas de la Práctica en Medicina/normas , Encuestas y Cuestionarios , Pancreatectomía , Vigilancia de la PoblaciónRESUMEN
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.