scholarly journals Trends and variation in unsafe prescribing of methotrexate: a cohort study in English NHS primary care

2020 ◽  
Vol 70 (696) ◽  
pp. e481-e488 ◽  
Author(s):  
Brian MacKenna ◽  
Helen J Curtis ◽  
Alex J Walker ◽  
Richard Croker ◽  
Seb Bacon ◽  
...  
Keyword(s):  
Primary Care ◽  
Cohort Study ◽  
Retrospective Cohort ◽  
National Level ◽  
Freedom Of Information ◽  
Substantial Variation ◽  
England And Wales ◽  
National Guidance ◽  
High Doses ◽  
Over Time

BackgroundPrescribing high doses of methotrexate increases the potentially fatal risk of toxicity. To minimise risk, it is recommended that only 2.5 mg tablets are used.AimTo describe trends in GP prescribing of methotrexate over time; the harm associated with methotrexate errors at a national level; ascertain variation between practices and clinical commissioning groups (CCGs) in their implementation of the safety guidance; and map current variations at CCG and practice level.Design and settingA retrospective cohort study of English GP prescribing data (August 2010–April 2018), and data acquired via freedom of information (FOI) requests.MethodThe main outcome measures were: variation in ratio of non-adherent/adherent prescribing, geographically and over time, between practices and CCGs; and description of responses to FOI requests.ResultsOf 7349 practices in England, 1689 prescribed both 2.5 mg and 10 mg tablets to individual patients in 2017, breaching national guidance. In April 2018, 697 practices (≥90th percentile) prescribed >14.3% of all methotrexate as 10 mg tablets, likewise breaching national guidance. The 66 practices at ≥99th percentile gave >52.4% of all prescribed methotrexate in the form of 10 mg tablets. The prescribing of 10 mg tablets fell during the study period, with 10 mg tablets as a proportion of all prescribed methotrexate tablets falling from 9.1% to 3.4%. Twenty-one deaths caused by methotrexate poisoning were reported from 1993–2017 in England and Wales.ConclusionThe prevalence of unsafe methotrexate prescribing has reduced but remains common, with substantial variation between practices and CCGs. The authors recommend investment in better strategies around implementation. As 21 deaths that occurred from 1993–2017 in England and Wales were attributed to methotrexate poisoning, the coroners’ reports for these deaths should be reviewed to identify recurring themes.

scholarly journals Trends and variation in unsafe prescribing of methotrexate: a cohort study in English NHS primary care

2019 ◽  
Author(s):  
Brian MacKenna ◽  
Helen J Curtis ◽  
Alex J Walker ◽  
Richard Croker ◽  
Seb Bacon ◽  
...  
Keyword(s):  
Primary Care ◽  
Cohort Study ◽  
Retrospective Cohort ◽  
Geographical Variation ◽  
Freedom Of Information ◽  
Substantial Variation ◽  
National Guidance ◽  
General Practices ◽  
Safety Recommendations ◽  
Over Time

AbstractObjectiveTo describe trends and geographical variation in methotrexate prescribing that breaches national safety recommendations; deaths from methotrexate poisoning; and associated litigation.MethodsA retrospective cohort study of English NHS primary care prescribing data, complemented by information obtained through Freedom of Information (FOI) requests. The main outcome measures were: (1) variation in ratio of breaching / adherent prescribing, geographically and over time, between General Practices and Clinical Commissioning Groups; (2) description of responses to FOI requests.ResultsOut of 7349 NHS General Practices in England, 1689 practices prescribed both 2.5mg and 10mg tablets to individual patients in 2017, breaching national guidance. In April 2018, 697 practices (at the 90th centile and above) prescribed at least 14.3% of all methotrexate as 10mg tablets, breaching national guidance. The 66 practices at the 99th percentile and above gave at least 52.4% of all prescribed methotrexate in the form of 10 mg tablets. The prescribing of 10mg tablets has fallen over 7 years, with 10mg tablets as a proportion of all methotrexate tablets falling from 9.1% to 3.4%. 21 deaths caused by methotrexate poisoning have been reported from 1993-2017.ConclusionsThe prevalence of unsafe methotrexate prescribing has reduced but it remains common, with substantial variation between organisations. We recommend the NHS invests in better strategies around implementation of safety recommendations. 21 deaths have been attributed to methotrexate poisoning but with no further details easily available: the full coroners reports for these deaths should be reviewed to identify recurring themes.

scholarly journals Trends and variation in prescribing of suboptimal statin treatment regimes: a cohort study in English primary care

2019 ◽  
Author(s):  
Helen J Curtis ◽  
Alex J Walker ◽  
Brian MacKenna ◽  
Richard Croker ◽  
Ben Goldacre
Keyword(s):  
Primary Care ◽  
Logistic Regression ◽  
Cohort Study ◽  
Behaviour Change ◽  
High Intensity ◽  
Mixed Effects ◽  
Substantial Variation ◽  
Practice Characteristics ◽  
National Guidance ◽  
Prescribing Behaviour

AbstractObjectivesWe set out to describe trends and variation in statin prescribing in England that breaches 2014 national guidance on “high-intensity” statins. We identify factors associated with breaching; and assess the feasibility of rapid prescribing behaviour change.Design, Setting and ParticipantsRetrospective cohort study in NHS primary care in England, including all 8,142 standard general practices from August 2010 to March 2019.Main Outcome MeasuresWe categorised statins as high or low/medium-intensity based on two different thresholds, and calculated the proportion prescribed below these thresholds across all practices. We plotted trends and geographical variation, carried out mixed effects logistic regression to identify practice characteristics associated with breaching guidance, and used indicator saturation to identify practices exhibiting sudden changes in prescribing.ResultsWe included all 8,142 practices across the study period. The proportion of statin prescriptions below the recommended 40% LDL-lowering threshold decreased gradually since 2012 from 80% to 45%; the proportion below a pragmatic 37% threshold decreased from 30% to 18%. The 2014 guidance had minimal impact on these trends. We found wide variation between practices (interdecile ranges 20% to 85% and 10% to 30% respectively in 2018). Mixed effects logistic regression did not identify practice characteristics strongly associated with breaching guidance. Indicator saturation identified several practices exhibiting sudden changes in prescribing towards greater guideline compliance.ConclusionsBreaches of English guidance on choice of statin remain common, with substantial variation between GP practices. Some practices and regions have implemented rapid change, indicating the feasibility of rapid prescribing behaviour change. We discuss the potential for a national strategic approach, using data and evidence to optimise care, including targeted education alongside audit and feedback to outliers through services such as OpenPrescribing.SummaryWhat is already known on this topicEnglish national guidance recommends the use of a high-intensity statin, capable of reducing LDL (low-density lipoprotein) cholesterol by 40% or more. Adherence at the time of guideline release was low, but has not been documented since.What this study addsAdherence is improving, but breaches of national guidance remain common, with 45% of prescriptions below the recommended strength, and there is very substantial variation between practices. Some practices have exhibited rapid positive change in prescribing, which indicates that better adherence could readily be achieved. We have produced a live data tool allowing anyone to explore any practice’s current statin prescribing behaviour.

A Retrospective Cohort Study of SARS-CoV-2 Infection in Hypertenses Patients in a Primary Care Center

2020 ◽  
Author(s):  
Esther Hernandez Castilla ◽  
Lucia Vallejo Serrano ◽  
Monica Saenz Ausejo ◽  
Beatriz Pax Sanchez ◽  
Katharina Ramrath ◽  
...  
Keyword(s):  
Primary Care ◽  
Cohort Study ◽  
Retrospective Cohort Study ◽  
Retrospective Cohort ◽  
Care Center ◽  
Primary Care Center

scholarly journals Reinfection Rates Among Patients Who Previously Tested Positive for Coronavirus Disease 2019: A Retrospective Cohort Study

2021 ◽  
Author(s):  
Megan M Sheehan ◽  
Anita J Reddy ◽  
Michael B Rothberg
Keyword(s):  
Cohort Study ◽  
Retrospective Cohort Study ◽  
Retrospective Cohort ◽  
Symptomatic Infection ◽  
Symptomatic Disease ◽  
Viral Shedding ◽  
History Of ◽  
Polymerase Chain ◽  
Prior Infection ◽  
Over Time

Abstract Background Protection afforded from prior disease among patients with coronavirus disease 2019 (COVID-19) infection is unknown. If infection provides substantial long-lasting immunity, it may be appropriate to reconsider vaccination distribution. Methods This retrospective cohort study of 1 health system included 150 325 patients tested for COVID-19 infection via polymerase chain reaction from 12 March 2020 to 30 August 2020. Testing performed up to 24 February 2021 in these patients was included. The main outcome was reinfection, defined as infection ≥90 days after initial testing. Secondary outcomes were symptomatic infection and protection of prior infection against reinfection. Results Of 150 325 patients, 8845 (5.9%) tested positive and 141 480 (94.1%) tested negative before 30 August. A total of 1278 (14.4%) positive patients were retested after 90 days, and 62 had possible reinfection. Of those, 31 (50%) were symptomatic. Of those with initial negative testing, 5449 (3.9%) were subsequently positive and 3191 of those (58.5%) were symptomatic. Protection offered from prior infection was 81.8% (95% confidence interval [CI], 76.6–85.8) and against symptomatic infection was 84.5% (95% CI, 77.9–89.1). This protection increased over time. Conclusions Prior infection in patients with COVID-19 was highly protective against reinfection and symptomatic disease. This protection increased over time, suggesting that viral shedding or ongoing immune response may persist beyond 90 days and may not represent true reinfection. As vaccine supply is limited, patients with known history of COVID-19 could delay early vaccination to allow for the most vulnerable to access the vaccine and slow transmission.

scholarly journals Treatment of chronic noncancer pain in patients on opioid therapy in primary care: A retrospective cohort study

2019 ◽  
Vol 153 (1) ◽  
pp. 52-58
Author(s):  
Arden R. Barry ◽  
Chantal E. Chris
Keyword(s):  
Primary Care ◽  
Cohort Study ◽  
Back Pain ◽  
Retrospective Cohort Study ◽  
Retrospective Cohort ◽  
Opioid Therapy ◽  
Opioid Agonist ◽  
Chronic Noncancer Pain ◽  
Opioid Dose ◽  
Noncancer Pain

Background: This study sought to characterize the real-world treatment of chronic noncancer pain (CNCP) in patients on opioid therapy in primary care. Methods: A retrospective cohort study from 2014-18 was conducted at a multidisciplinary primary care clinic in Chilliwack, British Columbia. Included were adults on daily opioid therapy for CNCP. Patients receiving palliative care or ≤1 visit were excluded. Outcomes of interest included use of opioid/nonopioid pharmacotherapy, number/frequency of visits and proportion of patients able to reduce/discontinue opioid therapy. Results: Seventy patients (mean age 53 years, 53% male, 51% back pain) were included. Median follow-up was 6 visits over 12 months. Sixty-two patients (89%) reduced their opioid dose, 6 patients had no change and 2 patients required a dose increase. Mean opioid dose was reduced from 183 to 70 mg morphine equivalents daily. Twenty-four patients (34%) discontinued opioid therapy, 6 patients (9%) transitioned to opioid agonist therapy and 6 patients (9%) breached their opioid treatment agreement. Nonopioid pharmacotherapy included nonsteroidal anti-inflammatory drugs (64%), gabapentinoids (63%), tricyclic antidepressants (56%) and nabilone (51%). Discussion: Over half of patients were no longer on opioid therapy by the end of the study. Most patients had a disorder (e.g., back pain) for which opioids are generally not recommended. Overall mean opioid dose was reduced from baseline by approximately 60% over 1 year. Lack of access to specialized pain treatments may have accounted for high nonopioid pharmacotherapy usage. Conclusions: This study demonstrates that treatment of CNCP and opioid tapering can successfully be achieved in a primary care setting. Can Pharm J (Ott) 2020;153:xx-xx.

scholarly journals Triptan use after starting prophylactic migraine treatment: A retrospective cohort study in a primary care population

Cephalalgia ◽  
2014 ◽  
Vol 34 (11) ◽  
pp. 927-932 ◽  
Author(s):  
Antonia FH Smelt ◽  
Willem JJ Assendelft ◽  
Christel E van Dijk ◽  
Jeanet W Blom
Keyword(s):  
Primary Care ◽  
Clinical Trials ◽  
Cohort Study ◽  
Retrospective Cohort ◽  
Daily Practice ◽  
Rank Test ◽  
Migraine Treatment ◽  
Prophylactic Effect ◽  
Primary Care Population ◽  
Wilcoxon Rank Test

Background Clinical trials on the prophylactic effect of propranolol and metoprolol for migraine show that starting this medication leads to a decrease in the use of attack medication of 0.9–8.9 doses per month. However, studies in daily practice are lacking. Methods We compared the number of triptans prescribed in the six months before and the six months after the start of propranolol/metoprolol in a Dutch national representative primary care cohort. Results Of the 168 triptan-using patients who started with propranolol or metoprolol, the number of triptans prescribed before starting was 4.6 doses per month. The number of triptans prescribed six months before compared with six months after starting propranolol/metoprolol decreased with 1.0 dose per month (Wilcoxon rank test; p = 0.000). Conclusion In this primary care population, although the number of triptans prescribed decreased after starting propranolol or metoprolol, the decrease is relatively small compared to data from clinical trials.

scholarly journals Influence of weekday of admission and level of distress on length of hospital stay in patients with low back pain: a retrospective cohort study

2021 ◽  
Vol 22 (1) ◽  
Author(s):  
Emanuel Brunner ◽  
André Meichtry ◽  
Davy Vancampfort ◽  
Reinhard Imoberdorf ◽  
David Gisi ◽  
...  
Keyword(s):  
Primary Care ◽  
Cohort Study ◽  
Low Back Pain ◽  
Back Pain ◽  
Retrospective Cohort Study ◽  
Retrospective Cohort ◽  
Negative Binomial ◽  
Length Of Hospital Stay ◽  
Binomial Model ◽  
Low Back

Abstract Background Low back pain (LBP) is often a complex problem requiring interdisciplinary management to address patients’ multidimensional needs. Providing inpatient care for patients with LBP in primary care hospitals is a challenge. In this setting, interdisciplinary LBP management is often unavailable during weekends. Delays in therapeutic procedures may result in a prolonged length of hospital stay (LoS). The impact of delays on LoS might be strongest in patients reporting high levels of psychological distress. Therefore, this study investigates the influence of weekday of admission and distress on LoS of inpatients with LBP. Methods This retrospective cohort study was conducted between 1 February 2019 and 31 January 2020. In part 1, a negative binomial model was fitted to LoS with weekday of admission as a predictor. In part 2, the same model included weekday of admission, distress level, and their interaction as covariates. Planned contrast was used in part 1 to estimate the difference in log-expected LoS between group 1 (admissions Friday/Saturday) and the reference group (admissions Sunday-Thursday). In part 2, the same contrast was used to estimate the corresponding difference in (per-unit) distress trends. Results We identified 173 patients with LBP. The mean LoS was 7.8 days (SD = 5.59). Patients admitted on Friday (mean LoS = 10.3) and Saturday (LoS = 10.6) had longer stays, but not those admitted on Sunday (LoS = 7.1). Analysis of the weekday effect and planned contrast showed that admission on Friday or Saturday was associated with a significant increase in LoS (log ratio = 0.42, 95% CI = 0.21 to 0.63). A total of 101 patients (58%) returned questionnaires, and complete data on distress were available from 86 patients (49%). According to the negative binomial model for LoS and the planned contrast, the distress effect on LoS was significantly influenced (difference in slopes = 0.816, 95% CI = 0.03 to 1.60) by dichotomic weekdays of admission (Friday/Saturday vs. Sunday-Thursday). Conclusions Delays in interdisciplinary LBP management over the weekend may prolong LoS. This may particularly affect patients reporting high levels of distress. Our study provides a platform to further explore whether interdisciplinary LBP management addressing patients’ multidimensional needs reduces LoS in primary care hospitals.

scholarly journals LDL-cholesterol change and goal attainment following statin intensity titration among Asians in primary care: a retrospective cohort study

2021 ◽  
Vol 20 (1) ◽  
Author(s):  
Hao Sen Andrew Fang ◽  
Qiao Gao ◽  
Mong Li Lee ◽  
Wynne Hsu ◽  
Ngiap Chuan Tan
Keyword(s):  
Primary Care ◽  
Clinical Trials ◽  
Cohort Study ◽  
Real World ◽  
Retrospective Cohort Study ◽  
Retrospective Cohort ◽  
Goal Attainment ◽  
Real World Data ◽  
World Data ◽  
Asian Patients

Abstract Background Clinical trials have demonstrated that either initiating or up-titrating a statin dose substantially reduce Low-Density Lipoprotein-Cholesterol (LDL-C) levels. However, statin adherence in actual practice tends to be suboptimal, leading to diminished effectiveness. This study aims to use real-world data to determine the effect on LDL-C levels and LDL-C goal attainment rates, when selected statins are titrated in Asian patients. Methods A retrospective cohort study over a 5-year period, from April 2014 to March 2019 was conducted on a cohort of multi-ethnic adult Asian patients with clinical diagnosis of Dyslipidaemia in a primary care clinic in Singapore. The statins were classified into low-intensity (LI), moderate-intensity (MI) and high-intensity (HI) groups according to the 2018 American College of Cardiology and American Heart Association (ACC/AHA) Blood Cholesterol Guidelines. Patients were grouped into “No statin”, “Non-titrators” and “Titrators” cohorts based on prescribing patterns. For the “Titrators” cohort, the mean percentage change in LDL-C and absolute change in LDL-C goal attainment rates were computed for each permutation of statin intensity titration. Results Among the cohort of 11,499 patients, with a total of 266,762 visits, there were 1962 pairs of LDL-C values associated with a statin titration. Initiation of LI, MI and HI statin resulted in a lowering of LDL-C by 21.6% (95%CI = 18.9–24.3%), 28.9% (95%CI = 25.0–32.7%) and 25.2% (95%CI = 12.8–37.7%) respectively. These were comparatively lower than results from clinical trials (30 to 63%). The change of LDL-C levels due to up-titration, down-titration, and discontinuation were − 12.4% to − 28.9%, + 13.2% to + 24.6%, and + 18.1% to + 32.1% respectively. The improvement in LDL-C goal attainment ranged from 26.5% to 47.1% when statin intensity was up-titrated. Conclusion In this study based on real-world data of Asian patients in primary care, it was shown that although statin titration substantially affected LDL-C levels and LDL-C goal attainment rates, the magnitude was lower than results reported from clinical trials. These results should be taken into consideration and provide further insight to clinicians when making statin adjustment recommendations in order to achieve LDL-C targets in clinical practice, particularly for Asian populations.

A Retrospective Cohort Study Evaluating Surgical Aptitude Over Time in a New Male-To-Female Penoscrotal Vaginoplasty Program

2020 ◽  
Vol 17 (9) ◽  
pp. 1787-1794
Author(s):  
Rachel M. Whynott ◽  
Karen Summers ◽  
Riley Mickelsen ◽  
Satish Ponnuru ◽  
Joshua A. Broghammer ◽  
...  
Keyword(s):  
Cohort Study ◽  
Retrospective Cohort Study ◽  
Retrospective Cohort ◽  
Male To Female ◽  
Over Time
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