Identification of waste: DOWNTIME in the outpatient prescription services at the pharmacy installation of Rumah Sakit Islam Siti Hajar Mataram

Background: The hospital pharmacy installation is a health service unit that is required to provide professional services and improve quality which is oriented towards achieving patient satisfaction. Waste identification in pharmaceutical services is important because it has an impact on stakeholder satisfaction. Objective: Identifying waste using the DOWNTIME method for the outpatient prescription services at the pharmacy installation of Rumah Sakit Islam Siti Hajar Mataram. Methods: The study used the cross-sectional design, with the population being all outpatients who were provided with pharmaceutical services during February – April 2019 as well as all staff. Data were tabulated and analyzed descriptively. Critical waste was obtained through questionnaires and the root causes of critical waste were obtained through in-depth interviews with 5-why methods. Results: Waste waiting had the highest rate compared to other wastes, reaching 44% or 53 out of 121 respondents, followed by inventory (26%), extra processing (19%), transportation (14%), defects (14%), motion (13%), over production (8%), and non-utilized skills (7%). Meanwhile, from the staff respondents, waiting was also the highest waste (18%), followed by inventory (16%), motion (13%), over production (12%), transportation (12%), non-utilized skills (10%), extra processing (10%), and defects (9%). The root cause of waste waiting was the frequent drug unavailability due to delays in payment of services from the cooperating party to the hospital as well as the narrow service areas. Conclusion:Waste waiting became the critical waste with the highest percentage of dissatisfaction in the patient respondents (44%) and staff respondents (18%). Keywords: Waste, DOWNTIME, outpatient prescription services, pharmacy installation of RSI Siti Hajar Mataram

Anticoagulation Therapy in Cancer Patients with Thrombosis in the Outpatient Sector of Germany (The CERTIFICAT Initiative)—German Practice of Anticoagulation Therapy of Cancer Patients with Thrombosis

Objective This article aims to investigate the reality of anticoagulation treatment for cancer patients with thrombosis in the outpatient sector of Germany. Methods For the analysis period 2012 to 2015, anonymized data from 4.1 million statutory insured patients were analyzed. Cancer patients with incident thrombosis and an outpatient prescription of anticoagulant drugs were identified and evaluated for three subsequent quarters with regard to anticoagulant use. Results A total of 7,313 cancer patients with incident thrombosis (ICD-10: I80*) were evaluated. About, 90% of patients with thromboses were diagnosed and treated in the ambulatory sector. More than 80% of the prescriptions were issued by general practitioners. And 57% of patients were anticoagulated predominantly (>50% of the time) with different low-molecular-weight heparins (LMWHs), 24% predominantly with vitamin K antagonists (VKAs), and 17% with direct oral anticoagulants (DOACs). Anticoagulants were prescribed for an average of 4.5 months. LMWH had a substantially longer prescription period (90–135 days) than VKA (53 days) or DOAC (47 days). Gastrointestinal bleeding in conjunction with hospitalization was documented in 1.76% of patients with a range of 1.3 to 3% for the different LMWHs. Conclusion The prescription practice documented by this representative and comprehensive evaluation demonstrates an anticoagulation duration in accordance with the guidelines, although the choice of the respective anticoagulant was often not in compliance with the contemporary label or guidelines.

Optimizing Post-Cesarean Opioid Prescription Practices at Mayo Clinic: A Quality Improvement Initiative

Objective Optimal prescriptions practices of opioids in the post-cesarean period remain controversial. The primary aim of this initiative was to minimize unused prescription narcotic medication, with a goal of ≤4 leftover pills of 5-mg oxycodone at postoperative day (POD) 14 without affecting pain or satisfaction measures. Study Design This was a prospective longitudinal quality improvement (QI) initiative starting in 2017 utilizing the DMAIC methodology. The measurement phase consisted of validated surveys over 3 months, along with chart review to determine current institutional prescription practices and predictors of outpatient opioid use. Resulting recommendations were adopted, and 1 year later, all patients undergoing cesarean were surveyed for 3 months to determine the effectiveness of the intervention. The study was approved by the Department's QI Committee. Results The response rate was 48%, with 50 of 101 patients completing surveys pre-intervention and 52 of 111 post-intervention. Pre-intervention, surplus medication was predicted (p <0.05) only by the quantity of the opioid prescription. In addition, patients who required ≤37.5 morphine milligram equivalents (MMEs) during the inpatient postoperative stay did not require outpatient narcotic prescriptions. Thereafter, a strategy of matching inpatient use to outpatient prescription 1:1 in a linear regression model (p <0.001, R 2 0.55) optimally matched patient needs up to 200 MME. In the post-intervention survey, mean (SD) prescription decreased from 17.6 (13.7) MME to 8.4 (8.3) MME (p <0.01); 39% compared with 16% of women were discharged without a prescription (p <0.01); and amongst all patients 82.7% compared with 59.6% (p <0.01) had ≤4 pills remaining without differences in patient satisfaction or pain perception. Conclusion This initiative highlights a practical approach to QI utilizing industry techniques in health care. This approach resulted in significant reductions in over-prescription and unused medication, without impacting pain or satisfaction scores. Key Points

The Outpatient Prescribing of Silver Sulfadiazine in Al-Kharj

Aim: The aim of the present study was to describe the outpatient prescription of silver sulfadiazine in Al-Kharj. Methodology: This study was conducted in a public hospital in Alkharj. The data were collected from the outpatient pharmacy in the hospital and includes outpatients who received silver sulfadiazine in 2018. Results: All of the silver sulfadiazine prescriptions were prescribed for 7 days. The prescriptions were made mainly by residents (96.67%). Most of the prescriptions were prescribed by emergency department (90.00%). Conclusion: The use of silver sulfadiazine was uncommon in Alkharj possibly due to the use of effective natural medicines. Silver sulfadiazine could lead to several adverse effects so it is important to increase the awareness about the wise use of silver sulfadiazine and other topical antibiotics.

Utilization of Intravenous Ribavirin Among Reproductive Age Adults in 2010–2017: A Population-Based Study in the Yinzhou District, Ningbo City of China

Background: Intravenous (IV) ribavirin is not approved in US and European Union, but it is authorized in China. Significant teratogenic and embryocidal effects of ribavirin have been found in almost all animal studies, it is critical to investigate the prevalence and trends of the utilization of IV ribavirin among reproductive age population.Objective: To evaluate the prevalence and trends of IV ribavirin use among reproductive-age population in 2010–2017.Methods: The study design of our study is retrospective cross-sectional study based on healthcare database. We identified and extracted the data of residents aged 18–44 years by using Yinzhou healthcare information database at 21 January, 2018. A cohort of IV ribavirin users were identified through outpatient prescription records in 3 general hospitals and 24 community health centers from 2010 to 2017. We reported the number, proportion, and prevalence of the exposure to IV ribavirin stratified by sex, age, marital status, education level, occupation, hospital level, calendar year, diagnosis, and dosage. The overall trends of IV ribavirin use, and the trends in different levels of hospital and common diagnoses were further analyzed and described.Result: During the study period, the prevalence of IV ribavirin use among reproductive-age adults was 6.02% (48,287/801,667). Relatively higher prevalence were found in adults aged 40–44 (8.04%, 95% CI: 7.90–8.17), unmarried patients (8.91%, 95% CI: 8.74–9.08), and who had more than 9 years of education (6.82%, 95% CI: 6.74–6.90). Compared to secondary and tertiary hospitals, IV ribavirin was more likely to be dispensed in primary hospitals (19.44%, 95% CI: 19.28–19.61). The most common diagnoses were acute upper respiratory infections (AURIs), accounting for 80% of the patients exposed to IV ribavirin. For patients with AURIs, the prevalence of IV ribavirin was nearly 30%. Overall, the prevalence of IV ribavirin use decreased from 1.72% in 2010 to 0.24% in 2017.Conclusion: We found IV ribavirin was mainly used for AURIs which suggested that a large amount of IV ribavirin use was probably inappropriate. The prevalence was decreasing by 87% over the past 8 years, and we encourage clinicians and pharmacists to continually avoid inappropriate use of IV ribavirin.

The association between immunosuppressants use and COVID-19 adverse outcome: National COVID-19 cohort in South Korea

SummaryBackgroundThere is uncertainty of the effect of immunosuppression, including corticosteroids, before COVID-19 infection on COVID-19 outcomes. The aim of this study was to investigate the relationship between prehospitalization immunosuppressants use (exposure), and COVID-19 patient outcomes.MethodsWe conducted a population-based retrospective cohort study using a nationwide healthcare claims database of South Korea as of May 15, 2020. Confirmed COVID-19 infection in hospitalized individuals aged 40 years or older were included for analysis. We defined exposure variable by using inpatient and outpatient prescription records of immunosuppressants from the database. Our primary outcome was a composite endpoint of all-cause death, intensive care unit (ICU) admission, and mechanical ventilation use. Inverse probability of treatment weighting (IPTW)-adjusted logistic regression analyses were used, to estimate odds ratio (OR) and 95% confidence intervals, comparing immunosuppressants users and non-users.FindingsWe identified 4,349 patients, for which 1,356 were immunosuppressants users and 2,903 were non-users. Patients who used immunosuppressants were at increased odds of the primary outcome of all-cause death, ICU admission and mechanical ventilation use (IPTW OR 1.32; 95% CI: 1.06 – 1.63). Patients who used corticosteroids were at increased odds of the primary outcome (IPTW OR 1.33; 95% CI: 1.07 – 1.64).InterpretationWe support the latest guidelines from the CDC, that people on immunosuppressants are at high risk of severe COVID-19 and immunocompromised people may need booster COVID-19 vaccinations.FundingYGC’s work was partially supported by 2020R1G1A1A01006229 awarded by the National Research Foundation of Korea.Research in contextEvidence before this studyIt is currently unclear whether immunosuppressants use before COVID-19 is associated with adverse outcomes.Added value of this studyImmunosuppressants in patients with COVID-19 were at increased odds of the primary outcome of all-cause death, ICU admission and mechanical ventilation use.Implications of all the available evidenceImmunosuppressant use before COVID-19 is associated with adverse outcomes and immunocompromised people may need booster COVID-19 vaccination.

The association between postpartum hemorrhage and postpartum depression: A Swedish national register-based study

Background Postpartum hemorrhage is an important cause of maternal death and morbidity. However, it is unclear whether women who experience postpartum hemorrhage are at an increased risk of postpartum depression. Objectives To examine whether postpartum hemorrhage is associated with postpartum depression. Methods We conducted a national register-based cohort study of 486,476 Swedish-born women who had a singleton livebirth between 2007 and 2014. We excluded women with pre-existing depression or who filled a prescription for an antidepressant before childbirth. We classified postpartum depression up to 12 months after giving birth by the presence of an International Classification of Diseases, version 10 (ICD-10) diagnosis code for depression or a filled outpatient prescription for an antidepressant. We used Cox proportional hazard models, adjusting for maternal sociodemographic and obstetric factors. Results Postpartum depression was identified in 2.0% (630/31,663) of women with postpartum hemorrhage and 1.9% (8601/455,059) of women without postpartum hemorrhage. In our unadjusted analysis, postpartum hemorrhage was not associated with postpartum depression (unadjusted hazard ratio (HR) = 1.06, 95% confidence interval (CI) 0.97–1.15). After adjusting for maternal age, parity, education, cohabitation status, maternal smoking status, and early pregnancy maternal BMI, gestational age, and birthweight, the association did not appreciably change, with confidence intervals overlapping the null (adjusted HR = 1.08, 95% CI 0.99, 1.17). Conclusions Within a population-based cohort of singleton women in Sweden with no prior history of depression, postpartum hemorrhage was not associated with postpartum depression.