To describe the rates of pediatric antibiotic use across 6 countries on 3 continents.
Cross-national analysis of 7 pediatric cohorts in 6 countries (Germany, Italy, South Korea, Norway, Spain, and the US) was performed for 2008-2012. Antibiotic dispensings were identified and grouped into subclasses. We calculated the rates of antimicrobial prescriptions per person-year specific to each age group, comparing the rates across different countries.
A total of 74?744?302 person-years from all participating centers were included in this analysis. Infants in South Korea had the highest rate of antimicrobial consumption, with 3.41 prescribed courses per child-year during the first 2 years of life. This compares with 1.6 in Lazio, Italy; 1.4 in Pedianet, Italy; 1.5 in Spain; 1.1 in the US; 1.0 in Germany; and 0.5 courses per child-year in Norway. Of antimicrobial prescriptions written in Norway, 64.8% were for first-line penicillins, compared with 38.2% in Germany, 31.8% in the US, 27.7% in Spain, 25.1% in the Italian Pedianet population, 9.8% in South Korea, and 8% in the Italian Lazio population.
We found substantial differences of up to 7.5-fold in pediatric antimicrobial use across several industrialized countries from Europe, Asia, and North America. These data reinforce the need to develop strategies to decrease the unnecessary use of antimicrobial agents.
To compare the results of a randomised and an observational evaluation of the same policy that restricted reimbursement for nebulised respiratory medications in adult patients in a community setting.
Cluster randomised controlled trial and observational time series with historical controls.
Pharmacare, the government funded drug benefits plan for elderly people and patients receiving social assistance in British Columbia, Canada.
In the randomised controlled trial 104 clusters of medical practices, pair matched by geography and approximately by practice size, were randomised to the intervention group (449 patients affected by the policy on 1 March 1999), and the control group (offered a six month exemption, affecting 386 patients). The observational analysis included all Pharmacare beneficiaries (excluding the 386 exempt patients) who had used any nebulised drugs six months before the policy (4624 patients).
Pharmacare restricted reimbursement for nebulised bronchodilators, steroids, and cromoglycate to patients whose doctors applied for an individual patient's exemption, giving an appropriate clinical reason.
Number of contacts with doctors and services, emergency admissions to hospital, and utilisation of and expenditure for respiratory drugs in databases of British Columbia's Ministry of Health.
Contacts with doctors or emergency admissions to hospital did not increase in association with the restriction, regardless of the analytical approach. In the observational analysis, we found a reduction of C24 dollars per patient month in all nebulised drug use (95% confidence interval 19 to 29) and an increase of C3 dollars per patient month in all expenditure for inhalers (1.4 to 4.5). The randomised evaluation found savings of C8 dollars per patient month for nebulisers (P = 0.24) and no increase in spending on inhalers (P = 0.79). Correcting for 60% non-compliance by exempt doctors in a sensitivity analysis yielded similar results as the observational evaluation.
Observational as well as randomised analyses found moderate net savings and no increase in unintended healthcare outcomes after restricting reimbursement for nebulised respiratory drugs. Randomised policy trials are feasible and, if carefully implemented, likely to be concordant with observational evaluations.
The performance of standard comorbidity scores to control confounding is poorly defined in health care utilization data across elderly populations. We sought to evaluate and rank the performance of comorbidity scores across selected U.S. and Canadian elderly populations using health care utilization databases.
Cross-population validation study.
Study participants were residents age 65 years or older who had prescription drug coverage through state-funded programs selected from several large health care utilization databases available to the investigators: British Columbia, BC (N = 141,161), New Jersey, NJ (N = 235,881), and Pennsylvania, PA (N = 230,913).
We calculated 6 commonly used comorbidity scores for all subjects during the baseline year (1994 for NJ and PA, and 1995 for BC). These included scores based on diagnoses (Romano, Deyo, D'Hoore, Ghali) and prescription drugs (CDS-1, CDS-2). The study outcome was 1-year mortality. The performance of scores was measured by c-statistics derived from multivariate logistic regression that included age and gender.
Across these 4 large elderly populations, we found the same rank order of performance in predicting 1-year mortality after including age and gender in each model: Romano (c-statistic 0.754 to 0.771), Deyo (c-statistic 0.753 to 0.768), D'Hoore (c-statistic 0.745 to 0.760), Ghali (c-statistic 0.733 to 0.745), CDS-1 (c-statistic 0.689 to 0.738), CDS-2 (c-statistic 0.677 to 0.718), and age and gender alone (c-statistic 0.664 to 0.681). Performance was improved by an average of 6% by adding the number of different prescription drugs received during the past year.
Performance ranking of 6 frequently used comorbidity scores was consistent across selected elderly populations. We recommend that investigators use these performance data as one important factor when selecting a comorbidity score for epidemiologic analyses of health care utilization data.
Little is known about cross-national comparisons of the persistence of antihypertensive medication treatment, trends in persistence, and factors associated with persistence. The aim of this study was to describe and compare patterns of use of antihypertensive drugs in a population of elderly patients in the United States (Pennsylvania), Canada (British Columbia) and the Netherlands.
A retrospective cohort study of Medicare enrollees in a state pharmacy assistance programme in Pennsylvania (USA), residents from British Columbia (Canada) and residents from the Netherlands registered in the PHARMO database was conducted. Each population included patients 65 years and older who were initiated on blood pressure-lowering treatment between 1 January 1998 and 31 December 2003 and who had continuous follow-up for at least 365 days. In these populations, the proportion of patients with at least 180 consecutive days without medication available (non-persistence) were identified as were predictors of non-persistence using Cox proportional hazards.
A total of 9664 Medicare enrollees (USA), 25 377 residents from British Columbia and 24 603 residents from the Netherlands were evaluated. During the first year after the initiation of treatment, the percentage of patients with at least 180 days without medication was 23.3% in Pennsylvania, 23.4% in British Columbia and 24.0% in the Netherlands. After 6 years, these percentages increased to 41.1, 36.3 and 38.2%, respectively. Factors associated with non-persistence were different between the three countries.
Despite differences in factors associated with persistence, non-persistence patterns are strikingly similar in all three populations. This suggests that the problem of non-persistence transcends international boundaries.
Cites: N Engl J Med. 2006 Apr 20;354(16):1685-9716537662
Cites: J Am Geriatr Soc. 2000 Feb;48(2):214-710682953
Cites: N Engl J Med. 2001 Sep 20;345(12):851-6011565517
Cites: N Engl J Med. 2001 Sep 20;345(12):870-811565519
Antidepressant therapies are underused among older adults and could be further curtailed by patient cost-sharing requirements. The authors studied the effects of two sequential cost-sharing policies in a large, stable population of all British Columbia seniors: change from full prescription coverage to 10-25 dollars copayments (copay) in January 2002 and replacement with income-based deductibles and 25% coinsurance in May 2003.
PharmaNet data were used to calculate monthly dispensing of antidepressants (in imipramine-equivalent milligrams) among all British Columbia residents age 65 and older beginning January 1997 through December 2005. Monthly rates of starting and stopping antidepressants were calculated. Population-level patterns over time were plotted, and the effects of implementing cost-sharing policies on antidepressant use, initiation, and stopping were examined in segmented linear regression models.
Implementation of the copay policy was not associated with significant changes in level of antidepressant dispensing or the rate of dispensing growth. Subsequent implementation of the income-based deductible policy also did not lead to a significant change in dispensing level but led to a significant (p=.02) decrease in the rate of growth of antidepressant dispensing. The copay policy was associated with a significant (p=.01) drop in the frequency of antidepressant initiation among persons with depression. Income-based deductibles reduced the rate of increase in antidepressant initiation over time. Implementation of the copay and income-based deductible policies did not have significant effects on stopping rates.
Introducing new forms of medication cost sharing appears to have the potential to reduce some use and initiation of antidepressant therapy by seniors. The clinical consequences of such reduced use need to be clarified.
Depression imposes enormous burdens on the elderly. Despite this, rates of initiation of and adherence to recommended pharmacotherapy are frequently low in this population. Although initiatives such as the Medicare Modernization Act (MMA) have improved seniors' access to antidepressants, there are concerns that the patient cost-sharing incorporated in the MMA may have unintended consequences if it reduces essential drug use. Age-related pharmacokinetic and pharmacodynamic changes could make seniors particularly vulnerable to antidepressant regimens used inappropriately to save costs, increasing their risks of morbidity, hospitalizations, and nursing home placements. Two sequential large-scale "natural experiments'' in British Columbia provide a unique opportunity to evaluate the effect of cost sharing on outcomes and mental health service use among seniors. In January 2002 the province introduced a CAD 25 copay (CAD10 for low-income seniors). In May 2003 this copay policy was replaced by a second policy consisting of an income-based deductible, 25% coinsurance once the deductible was met, and full coverage once an out-of-pocket ceiling was met. The transition between the two policies is analogous to what many U.S. seniors experience when they transition from private insurance requiring copays to Medicare Part D requiring deductibles and coinsurance.
To evaluate whether declines in antidepressant initiation after the introduction of two drug cost-sharing policies in British Columbia were associated with increased use of physician services, hospitalizations, and nursing home admissions among all British Columbia residents aged 65+.
Records of physician service use, inpatient hospitalizations, and residential care admissions were obtained from administrative databases. Population-level patterns over time were plotted, and effects of implementing the cost-sharing policies examined in segmented linear regression models.
Neither policy affected the rates of visits to physicians or psychiatrists for depression, hospitalizations with a depression diagnosis, or long-term care admissions.
The cost-sharing policies studied may have contained non-essential antidepressant use without substantially increasing mental health service utilization. However, it is possible that the policies had effects that we were unable to detect, such as increasing rates of visits to social workers or psychologists or forcing patients to reduce other spending. Further, the sequential implementation of the policy changes, makes it difficult to estimate the effect of a direct change from full coverage to a coinsurance/income-based deductible policy.
It may be possible to design policies to contain non-essential antidepressant use without substantially increasing other service utilization or adverse events. However, because undertreatment remains a serious problem among depressed elderly, well-designed prescription drug policies should be coupled with interventions to address under-treatment.
Cites: N Engl J Med. 1978 Sep 28;299(13):690-4355881
Many patients who initiate statin (3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitor) therapy discontinue treatment within 1 year. We sought to estimate the rate at which patients reinitiate treatment after long periods of nonadherence and to determine whether reinitiation of treatment is linked to potentially modifiable factors such as physician visits, cholesterol testing, or other encounters with the health care system.
We studied new users of statins in British Columbia, Canada, who initiated treatment between January 1, 1997, and June 30, 2004, and who had an extended period of nonadherence, defined as at least 90 days after the completion of 1 prescription in which no refill for any statin medication was obtained. Survival analysis was used to estimate the rate of reinitiation of statin therapy. Case-crossover analysis was used to evaluate the predictors of reinitiation.
We identified 239 911 new users of statins, of whom 129 167 (53.8%) had a period of nonadherence that lasted for at least 90 days. Of these patients, an estimated 48% restarted treatment within 1 year and 60% restarted treatment within 2 years. Case-crossover analysis revealed events that were associated with a return to adherence, including visits with the physician who initiated the statin regimen (odds ratio [OR], 6.1; 95% confidence interval [CI], 5.9-6.3), a visit with another physician (OR, 2.9; 95% CI, 2.8-3.0), and a cholesterol test (OR, 1.5; 95% CI, 1.4-1.5). Incident myocardial infarction (OR, 12.2; 95% CI, 8.9-16.9) and other cardiovascular disease-related hospitalizations (OR, 3.6; 95% CI, 3.1-4.3) were also strong predictors of reinitiation of treatment.
Physicians should be aware that statin use is dynamic and that many patients have long periods of nonadherence. A follow-up visit with the physician who wrote the initial statin prescription and having a cholesterol test predicted reinitiation of statin therapy. Our results suggest that continuity of care combined with increased follow-up and cholesterol testing could promote long-term adherence by shortening or eliminating long gaps in statin use. This hypothesis should be confirmed in a randomized experiment.
With the growing need to provide prescription drug benefits to older patients and to contain costs, it will be necessary to direct that coverage so as to make expenditures as efficient as possible. We evaluated the clinical and economic consequences of coverage restriction for 3 leading proton pump inhibitors (PPIs) in a large-scale natural experiment.
The study design was a time-trend analysis in the setting of a provincial drug benefits program in British Columbia, Canada. We studied all British Columbia residents aged 66 or older (N = 501,104) using linked data on all prescription drug dispensings, physician services, and hospitalizations between January 2002 and June 2004. The new policy restricted coverage to rabeprazole and required treatment failure with a histamine H2 blocker. More widely used PPIs (omeprazole, pantoprazole, and lansoprazole) had to be paid for out of pocket, unless the physician requested an exemption. The main outcome measures were utilization of PPIs, drug discontinuation rates, gastrointestinal hemorrhage rates, and drug expenditures.
Utilization of the restricted PPIs declined sharply after the policy change (-14,850 daily doses per month per 10,000 residents, P