Antimicrobials enable modern medicine, but their efficacy is a limited resource. In the past 20 years, antimicrobial development has slowed dramatically while antimicrobial resistance continues to rise. In response to this, there has been an increased focus on strategically managing antimicrobial use with an approach called "antimicrobial stewardship." Antimicrobial stewardship programs have been endorsed by health systems, professional societies, regulators, and government. These programs have been shown to reduce antimicrobial use, slow the growth of antimicrobial resistance, and improve patient outcomes. This commentary will discuss recent mandates for antimicrobial stewardship, compare current approaches to teaching infectious diseases pharmacotherapy with the skills and knowledge required for antimicrobial stewardship, and provide recommendations for and examples of best practices in training student pharmacists to become antimicrobial stewards.
Publications
2018
BACKGROUND: Gaining a better understanding of dental prescribing can help identify opportunities for intervention regarding optimal medication use. The purpose of this study is to characterize opioid and antibiotic prescribing patterns of dentists in the United States for Medicare Part D beneficiaries.
METHODS: The authors conducted a retrospective cross-sectional analysis of national 2014 Medicare Part D Prescriber Public Use File data. Providers in the data set with dental-related disciplines were included (n = 99,797). Outcomes of interest were mean days' supply and mean number of claims reported per claim, beneficiary, and prescriber discipline.
RESULTS: Of the 6,724,372 dental prescription claims submitted, 3,947,848 (58.7%) and 1,312,796 (19.5%) were for antibiotics and opioids, respectively. Sixty-nine percent of dentists in the highest quartile of opioid prescribers were also in the highest quartile of antibiotic prescribers (r2 = 0.7778; P < .01). The mean (standard deviation) days' supply per claim was 6.9 (5.3) days (range, 1-90 days) for antibiotics and 3.6 (2.0) days (range, 1-44.5 days) for opioids. Of the 33,348 dental providers who prescribed opioids, 18,971 (56.9%) prescribed a mean opioid days per claim greater than the recommended duration of 3 days for acute pain.
CONCLUSION: Opioids and antibiotics are the medications most prescribed by dentists. On the basis of national recommendations and results of studies from other countries, the length of therapy prescribed may be excessive. Further studies should be conducted to assess appropriateness of dental prescriptions.
PRACTICAL IMPLICATIONS: Dentistry should be considered for antibiotic and opioid stewardship interventions along with medicine.
BACKGROUND: The Department of Veterans Affairs (VA) has implemented robust strategies to monitor prescription opioid dispensing, but these strategies have not accounted for opioids prescribed by non-VA providers. State-based prescription drug monitoring programs (PDMPs) are a potential tool to identify VA patients' receipt of opioids from non-VA prescribers, and recent legislation requires their use within VA.
OBJECTIVE: To evaluate VA physicians' perspectives and experiences regarding use of PDMPs to monitor Veterans' receipt of opioids from non-VA prescribers.
DESIGN: Qualitative study using semi-structured interviews.
PARTICIPANTS: Forty-two VA primary care physicians who prescribed opioids to 15 or more Veterans in 2015. We sampled physicians from two states with PDMPs (Massachusetts and Illinois) and one without prescriber access to a PDMP at the time of the interviews (Pennsylvania).
APPROACH: From February to August 2016, we conducted semi-structured telephone interviews that addressed the following topics regarding PDMPs: overall experiences, barriers to optimal use, and facilitators to improve use.
KEY RESULTS: VA physicians broadly supported use of PDMPs or desired access to one, while exhibiting varying patterns of PDMP use dictated by state laws and their clinical judgment. Physicians noted administrative burdens and incomplete or unavailable prescribing data as key barriers to PDMP use. To facilitate use, physicians endorsed (1) linking PDMPs with the VA electronic health record, (2) using templated notes to document PDMP use, and (3) delegating routine PDMP queries to ancillary staff.
CONCLUSIONS: Despite the time and administrative burdens associated with their use, VA physicians in our study broadly supported PDMPs. The application of our findings to ongoing PDMP implementation efforts may strengthen PDMP use both within and outside VA and improve the safe prescribing of opioids.
PURPOSE: Historical trends and factors likely to influence future pharmaceutical expenditures are discussed, and projections are made for drug spending in 2018 in nonfederal hospitals, clinics, and overall (all sectors).
METHODS: Drug expenditure data through calendar year 2017 were obtained from the IQVIA (formerly QuintilesIMS) National Sales Perspectives database and analyzed. New drug approvals, patent expirations, and other factors that may influence drug spending in hospitals and clinics in 2018 were also reviewed. Expenditure projections for 2018 for nonfederal hospitals, clinics, and overall (all sectors) were made based on a combination of quantitative analyses and expert opinion.
RESULTS: Total U.S. prescription sales in the 2017 calendar year were $455.9 billion, a 1.7% increase compared with 2016. The top drug based on expenditures was adalimumab ($17.1 billion), followed by insulin glargine and etanercept. Prescription expenditures in nonfederal hospitals totaled $34.2 billion, a 0.7% decrease in 2017 compared with 2016. Expenditures in clinics increased 10.9%, to a total of $70.8 billion. The decrease in spending in nonfederal hospitals was driven by lower utilization. The top 25 drugs by expenditures in nonfederal hospitals and clinics were dominated by specialty drugs.
CONCLUSION: We project a 3.0-5.0% increase in total drug expenditures across all settings, a 11.0-13.0% increase in clinics, and a 0.0-2.0% increase in hospital drug spending in 2018. Health-system pharmacy leaders should carefully examine their own local drug utilization patterns to determine their own organization's anticipated spending in 2018.
BACKGROUND: Overlapping use of opioids and benzodiazepines is associated with increased risk for overdose. Veterans receiving medications concurrently from the U.S. Department of Veterans Affairs (VA) and Medicare may be at higher risk for such overlap.
OBJECTIVE: To assess the association between dual use of VA and Medicare drug benefits and receipt of overlapping opioid and benzodiazepine prescriptions.
DESIGN: Cross-sectional.
SETTING: VA and Medicare.
PARTICIPANTS: All veterans enrolled in VA and Medicare Part D who filled at least 2 opioid prescriptions in 2013 (n = 368 891).
MEASUREMENTS: Outcomes were the proportion of patients with a Pharmacy Quality Alliance (PQA) measure of opioid-benzodiazepine overlap (≥2 filled prescriptions for benzodiazepines with ≥30 days of overlap with opioids) and the proportion of patients with high-dose opioid-benzodiazepine overlap (≥30 days of overlap with a daily opioid dose >120 morphine milligram equivalents). Augmented inverse probability weighting regression was used to compare these measures by prescription drug source: VA only, Medicare only, or VA and Medicare (dual use).
RESULTS: Of 368 891 eligible veterans, 18.3% received prescriptions from the VA only, 30.3% from Medicare only, and 51.4% from both VA and Medicare. The proportion with PQA opioid-benzodiazepine overlap was larger for the dual-use group than the VA-only group (23.1% vs. 17.3%; adjusted risk ratio [aRR], 1.27 [95% CI, 1.24 to 1.30]) and Medicare-only group (23.1% vs. 16.5%; aRR, 1.12 [CI, 1.10 to 1.14]). The proportion with high-dose overlap was also larger for the dual-use group than the VA-only group (4.7% vs. 2.3%; aRR, 2.23 [CI, 2.10 to 2.36]) and Medicare-only group (4.7% vs. 2.9%; aRR, 1.06 [CI, 1.02 to 1.11]).
LIMITATION: Data are from 2013 and cannot capture medications purchased without insurance; unmeasured confounding may remain in this cross-sectional study.
CONCLUSION: Among a national cohort of veterans dually enrolled in VA and Medicare, receiving prescriptions from both sources was associated with greater risk for receiving potentially unsafe overlapping prescriptions for opioids and benzodiazepines.
PRIMARY FUNDING SOURCE: U.S. Department of Veterans Affairs.
Objective. To examine trends in manuscript publication rates for abstracts presented at the 2000, 2005, 2010, and 2015 American Association of Colleges of Pharmacy (AACP) annual meetings. Methods. A systematic search of PubMed, Scopus, and Google Scholar was performed. "New" colleges and schools of pharmacy were defined as receiving accreditation after 1996. Contingency tables and t-tests were applied. Results. There were 1382 abstracts evaluated. The overall publication rate was 20% and there was no difference in publication rates over 15 years. The median time to publication for years 2000, 2005, and 2010 was 15 months. The most frequent journal for publication was the American Journal of Pharmaceutical Education. The primary analysis identified several predictors for publication, including collaboration, presence of a PhD pharmaceutical program or academic medical center, and use of inferential statistics. There was no difference in manuscript publication when comparing "new" and legacy schools. Conclusion. The publication rate of AACP abstracts has remained steady despite the increase in pharmacy schools and colleges and faculty. Collaboration among institutions was the strongest predictor for publication, highlighting its importance. The low publication rate observed may be attributed to a lack of training for junior faculty, insufficient forums to publish work, or misaligned motivations for scholarship among faculty. These barriers should be examined further.
A culture follow-up program with an emphasis on symptom assessment may limit antibiotic exposure in patients with Group A Streptococcus on throat culture. A quasi-experimental study of such patients was conducted in our Emergency Department and Urgent Care centers. During the prestewardship initiative phase (March 2011-June 2012), the standard of care for culture follow-up did not include symptom assessment prior to prescribing antibiotics. During the stewardship initiative phase (March 2015-June 2016), culture follow-up was completed with a focus on symptom assessment and antibiotic avoidance. Two-hundred eighty patients were included. Antibiotic prescribing at follow-up decreased from 97.0% to 71.3% (P < 0.001); overall appropriateness of therapy at follow-up, including symptom assessment, increased from 6.0% to 81.5% (P < 0.001). There was no difference in 72-h revisit between the pre- and poststewardship initiative groups (P = 0.121). This study demonstrated improved antimicrobial prescribing with initiation of a stewardship-focused culture follow-up program in the Emergency Department and Urgent Care centers.
Although physicians learn about new medical technologies from their peers, the magnitude and source of peer influence is unknown. We estimate the effect of peer adoption of three first-in-class medications (dabigatran, sitigliptin, and aliskiren) on physicians' own adoption of those medications. We included 11,958 physicians in Pennsylvania prescribing anticoagulant, antidiabetic, and antihypertensive medications. We constructed 4 types of peer networks based on shared Medicare and Medicaid patients, medical group affiliation, hospital affiliation, and medical school/residency training. Instrumental variables analysis was used to estimate the causal effect of peer adoption (fraction of peers in each network adopting the new drug) on physician adoption (prescribing at least the median number prescriptions within 15 months of the new drug's introduction). We illustrate how physician network position can inform targeting of interventions to physicians by computing a social multiplier. Dabigatran was adopted by 25.2%, sitagliptin by 24.5% and aliskiren by 8.3% of physicians. A 10-percentage point increase in peer adoption in the patient-sharing network led to a 5.90% (SE = 1.50%, p<0.001) increase in physician adoption of dabigatran, 8.32% (SE = 1.51%, p<0.001) increase in sitagliptin, and 7.84% increase in aliskiren adoption (SE = 2.93%, p<0.001). Peer effects through shared hospital affiliation were positive but not significant, and medical group and training network effects were not reliably estimated. Physicians in the top decile of patient-sharing network peers were estimated to have nearly 2-fold stronger influence on their peers' adoption compared to physicians in the top decile of prescribing volume. Limitations include lack of detailed clinical information and pharmaceutical promotion, variables which may influence physician adoption but which are unlikely to bias our peer effect estimates. Peer adoption, especially by those with whom physicians share patients, strongly influenced physician adoption of new drugs. Our study shows the potential for using information on physician peer networks to improve technology diffusion.
This study estimates the total costs associated with administering chimeric antigen receptor T-cell treatment.