Dismantling the Safety-Net Hospital: The Construction of “Underutilization” and Scarce Public Hospital Care

Safety-net hospitals are vulnerable to government financing. After the Nixon administration encouraged states to conduct utilization review to identify medical cost savings, federal campaigns against hospital subsidies placed public hospital systems in perilous states and paralleled efforts in cities to eliminate “underutilized” facilities. New York City mayor John Lindsay sought a political balance between community participation and the technocratic search for underused beds. Subsequent mayors Abe Beame and Ed Koch proved less sympathetic. With community participation limited to symbolic input on hospital administrator hiring, south Brooklyn, the Bronx, and Harlem all suffered closures. This article contributes to literature on urban governance and health care administration by showing how macroeconomic fiscal decision-making overrode local demands and eventually became microeconomic motivators between and within hospitals. Municipal hospitals and Community Accountability Boards debated austerity budgeting’s negative effects on chronic and epidemic disease readiness, while the Health and Hospitals Corporation framed deprivation as patient choice.

Regional variation in the potentially inappropriate first-line use of fluoroquinolones in Canada as a key to antibiotic stewardship? A drug utilization review study

Background Serious adverse effects of fluoroquinolone antibiotics have been described for more than decade. Recently, several drug regulatory agencies have advised restricting their use in milder infections for which other treatments are available, given the potential for disabling and possibly persistent side effects. We aimed to describe variations in fluoroquinolone use for initial treatment of urinary tract infection (UTI), acute bacterial sinusitis (ABS), and acute exacerbation of chronic obstructive pulmonary disease (AECOPD) in the outpatient setting across Canada. Methods Using administrative health data from six provinces, we identified ambulatory visits with a diagnosis of uncomplicated UTI, uncomplicated AECOPD or ABS. Antibiotic exposure was determined by the first antibiotic dispensed within 5 days of the visit. Results We identified 4,303,144 uncomplicated UTI events among 2,170,027 women; the proportion of events treated with fluoroquinolones, mostly ciprofloxacin, varied across provinces, ranging from 18.6% (Saskatchewan) to 51.6% (Alberta). Among 3,467,678 ABS events (2,087,934 patients), between 2.2% (Nova Scotia) and 11.2% (Ontario) were dispensed a fluoroquinolone. For 1,319,128 AECOPD events among 598,347 patients, fluoroquinolones, mostly levofloxacin and moxifloxacin, ranged from 5.8% (Nova Scotia) to 35.6% (Ontario). The proportion of uncomplicated UTI and ABS events treated with fluoroquinolones declined over time, whereas it remained relatively stable for AECOPD. Conclusions Fluoroquinolones were commonly used as first-line therapies for uncomplicated UTI and AECOPD. However, their use varied widely across provinces. Drug insurance formulary criteria and enforcement may be a key to facilitating better antibiotic stewardship and limiting potentially inappropriate first-line use of fluoroquinolones.

New Drug Formulary Management and Utilization: Evidence in Sex, Race, and Ethnicity: 2019-2020

Background It is well established that females and persons of racial and ethnic minorities are frequently underrepresented in clinical trials. These disparities are potentially important aspects of evidence-based formulary management and drug utilization review (DUR) processes. Objective The purpose of this study was to review the demographic composition of pivotal trials and post-approval study requirements for recent FDA-approved drugs, analyzing the representation of minority groups and its generalizability to the US population or corresponding disease state. Methods Drugs approved between July 2019 and June 2020 were identified and demographic data including race, ethnicity, and sex was extracted from their pivotal trials. Demographic data was compared to US demographics and/or the disease state demographics for the respective approved drug. Results There were a total of 85 drugs and 142 pivotal trials included in the study. Compared to the estimated US population, the minority groups with a statistically significant underrepresentation across all pivotal trials included Black or African Americans and American Indian or Alaska Natives. The Hispanic/Latinx population had a statistically significant underrepresentation in 55.4% of trials. Females had a statistically significant underrepresentation in 21.2% of trials when compared to the disease state demographics of the respective approved drug. Conclusion and Relevance Persons of minorities are underrepresented in the generation of evidence of safety and efficacy for many new drugs. Formulary management and DUR offer an integrated strategic opportunity for the clinical community to formally and carefully consider the data on sex, race, and ethnicity to address disparities in health care.

Suggestion of a simpler and faster influenza-like illness surveillance system using 2014–2018 claims data in Korea

Influenza is an important public health concern. We propose a new real-time influenza-like illness (ILI) surveillance system that utilizes a nationwide prospective drug utilization monitoring in Korea. We defined ILI-related claims as outpatient claims that contain both antipyretic and antitussive agents and calculated the weekly rate of ILI-related claims, which was compared to weekly ILI rates from clinical sentinel surveillance data during 2014–2018. We performed a cross-correlation analysis using Pearson’s correlation, time-series analysis to explore actual correlations after removing any dubious correlations due to underlying non-stationarity in both data sets. We used the moving epidemic method (MEM) to estimate an absolute threshold to designate potential influenza epidemics for the weeks with incidence rates above the threshold. We observed a strong correlation between the two surveillance systems each season. The absolute thresholds for the 4-years were 84.64 and 86.19 cases per 1000claims for claims data and 12.27 and 16.82 per 1000 patients for sentinel data. The epidemic patterns were more similar in the 2016–2017 and 2017–2018 seasons than the 2014–2015 and 2015–2016 seasons. ILI claims data can be loaded to a drug utilization review system in Korea to make an influenza surveillance system.

A RANDOMISED CONTROL TRIAL ON CEREBRO VASCULAR ACCIDENT PATIENTS WITH REFERENCE TO AETIOLOGY AND MANAGEMENT: 24 WEEKS, SINGLE-CENTER, PROSPECTIVE OBSERVATIONAL PILOT STUDY

Objectives: Stroke is one of the leading causes of death and long-term disability in world. Stroke is an important cause of premature death and disability in low-income and middle-income countries like India, largely driven by demographic changes and enhanced by the increasing prevalence of key modifiable risk factors. The main aim of our study was to assess the clinical profile with special reference to the etiology of the condition, the management, and drug utilization review. Methods: This is a hospital-based prospective observational randomized control trial which was conducted for a period of 6 months at Government General Hospital, Rajiv Gandhi Institute of Medical Sciences, Kadapa. Seventy-five patients were recruited based on study criteria. The data were analyzed and summarized as frequency and percentage by GraphPad Prism software using Microsoft Excel. Results: In a total of 75 patients, it was found that 45 and 30 patients were female. Maximum number of patients (i.e. 36 patients) belonged to 51–60 years age group. We observed that 52 patients were suffering from ischemic stroke, 21 patients were suffering from transient ischemic stroke, and only 2 patients were suffering from ischemic stroke and transient ischemic stroke. Among 75 patients studied, hypertension (62%), diabetes mellitus (28%), smoking (33%), and alcohol (33%) were the risk factors. Conclusion: In this study, ischemic stroke was most prevalent. Hypertension, that is, increase of blood pressure considered as one of the important and major risk factors for stroke occurrence and recurrence. Proper management includes non-pharmacological (physiotherapy) along with pharmacological treatment that included cardiovascular system drugs such as hypolipidemics, cognition enhancers, anticoagulants, and antihypertensive therapy.

Analysis of Alprostadil Injection in Real-World Usage and a Review of Literatures

Background：The irrational use of medicines has become a major problem worldwide. The World Health Organization (WHO) estimates that more than half of all medicines are prescribed, dispensed, or sold inappropriately, and advised the pursuit of the responsible use of medicines.In China regulations require that a pharmacist must audit the prescription.Alprostadil injection is a vasodilator and an inhibitor of platelet aggregation There is no obvious or clear indication for its use in the ear, nose and throat (ENT) Department. It came to our notice that in our hospital, alprostadil injection has been prescribed in the ENT Outpatient Department to treat some diseases. Aim: This utilization review on the use of alprostadil injection was carried out in the ear, nose and throat (ENT) Outpatient Department of our hospital to determine its utilization patterns and promote its rational use. Methods: A prescription survey was conducted, and detailed demographic information, including the patient’s age, gender, diagnosis and so on, were recorded in an Excel spreadsheet. The rationality for these prescriptions were retrospectively evaluated.Results: Based on the evaluation results, all alprostadil injections were found to be used off label in the Otolaryngology Department. Furthermore, 98.3% of the prescriptions were for the treatment of sudden hearing loss, 1.1% of the prescriptions for the diagnosis of hypoacusis were considered empirical and should have been more specific, and 0.6% of the prescriptions were for the treatment of Ménière’s disease and large vestibular aqueduct syndrome. There were various dosage regimens for alprostadil injection in clinical practice. However, there was no statistically significant difference in dosage between the different age groups. Moreover, most of the alprostadil injections were given by IV bolus, while 12.2% of patients received this by intravenous drip.Conclusion: The present review indicated that improvements should be made in the quality of prescriptions for alprostadil injection in the Otolaryngology Outpatient Department. Furthermore, there is no strong evidence to support the use of high doses. Future audits of such use may be combined with an awareness campaign to reduce and discourage the irrational use of off label medications.