OBSERVASI PENGKAJIAN RESEP SECARA ADMINISTRATIF PADA APOTEK X DI KABUPATEN BADUNG

Prescription screening is one of pharmaceutical care standards in Pharmacy which regulated in Permenkes RI No. 73 Tahun 2016. The aim of this research is to know about the implementation of one pharmaceutical care standards which is presription screening in one of pharmacies in Badung Regency. This research is descriptive observational. Data collection was performed by means of a retrospective (drug prescription data in January-May 2020) in X Pharmacy at Badung Regency with a total sample of 70 prescriptions. Based on the result of administrative screening of prescription, the percentage of incompleteness prescription at pharmacy X are patient name 2,86%, patient age 45,71%, gender 87,14%, body weight 97,14%, patient address 51,43%, doctor's license (SIP) 42,86%, phone number 14,28%, physician initial 40% and prescription date 7,14%. The doctor's prescription completeness has not fulfilled the administrative prescription completeness requirement according to Permenkes RI No. 73 of 2016.

GAMBARAN KEJADIAN MEDICATION ERROR DI INSTALASI GAWAT DARURAT RSU ELIM RANTEPAO

ABSTRACT Medication Error is an event that is detrimental to the patient due to errors in the administration of drugs during the handling of health personnel, which can actually be prevented. Data on incidents of medication errors at Elim Hospital, Rantepao in 2017 were 85 cases (0.085% of the total 98,892 prescription sheets served). This study aims to determine the incidence and the percentage of medication errors during the prescribing and dispensing phase in the Emergency Installation of Elim Hospital ,Rantepao. This research is a descriptive analysis with prospective data collection. The results showed that medication errors which occurred at prescribing stage included no prescription doctor's name was 9.19%, no medical record number was 6.13%, no doctor's initial was 99.61%, patient's name was not clear was 0.57% , there was no patient age, was 6.89%, no concentration / dosage was 2.68%, no dosage form was 52.10%, and no prescription date was 1.72%. While medication errors at the dispensing stage include taking the drug was 0.38% and the lack of drug prepared was 0.19%. Based on the results of the study, it can be concluded that the biggest occurrence of medication errors in Emergency Services at Elim Hospital, Rantepao was occurred in the prescribing phase.Keywords: medication error, prescribing, dispensing, Emergency Installation ABSTRAKMedication Error adalah kejadian yang merugikan pasien akibat kesalahan dalam pemberian obat selama penanganan tenaga kesehatan, yang sebetulnya dapat dicegah. Data insiden kejadian medication error RSU Elim Rantepao pada tahun 2017 yaitu sebanyak 85 kasus (0,085 % dari total 98.892 lembar resep yang dilayani). Penelitian ini bertujuan menentukan kejadian dan persentase medication error pada fase prescribing dan dispensing di Instalasi Gawat Darurat RSU Elim Rantepao. Penelitian ini merupakan penelitian yang bersifat analisis deskriptif dengan pengumpulan data secara prospektif. Hasil penelitian menunjukkan bahwa medication error yang terjadi pada tahap prescribing meliputi tidak ada nama dokter penulis resep 9,19%, tidak ada nomor rekam medik 6,13%, tidak ada paraf dokter 99,61%, nama pasien tidak jelas 0,57%, tidak ada usia pasien 6,89%, tidak ada konsentrasi/dosis sediaan 2,68%, tidak ada bentuk sediaan 52,10 %, dan tidak ada tanggal pembuatan resep 1,72%. Sedangkan medication error pada tahap dispensing meliputi salah pengambilan obat 0,38% dan obat ada yang kurang 0,19%. Berdasarkan hasil penelitian maka dapat disimpulkan bahwa kejadian medication error di Instalasi Gawat Darurat RSU Elim Rantepao terbesar yaitu terjadi pada fase prescribing.Kata-kata kunci : medication error , prescribing, dispensing, Instalasi Gawat Darurat

Efficacy and Safety of Direct Oral Factor Xa Inhibitors in 795 Morbidly Obese Patients

Background: Studies of acute venous thromboembolism (VTE) and non-valvular atrial fibrillation (AF) have shown comparable therapeutic efficacy and similar or lower bleeding risk for direct oral anticoagulants (DOACs) compared to warfarin. Because the representation of morbidly obese patients (BMI ≥40 kg/m2) in pivotal clinical trials has been minimal, efficacy and safety of DOACs in this population are unclear. Our goal was to investigate whether direct oral factor Xa inhibitors, apixaban and rivaroxaban, are as effective and safe as warfarin in morbidly obese (BMI ≥40) patients. Methods: Using our institutional database, we identified all adult patients at Montefiore Medical Center with BMI ≥40 who were started on anticoagulation with apixaban, rivaroxaban or warfarin, for either AF or VTE, between March 1, 2013 and March 1, 2017. We reviewed charts to obtain detailed information on patient demographics and to document clinical outcomes of recurrent VTE, ischemic stroke (CVA) and bleeding from the first prescription date to the earliest of a thrombotic event, discontinuation of medication, death, or June 30, 2017. VTE and CVA episodes were confirmed by imaging (compression sonography, CT scans, ventilation/perfusion scans, MRIs). Bleeding events were classified according to criteria from the Control of Anticoagulation Subcommittee of the International Society on Thrombosis and Haemostasis. Analyses were stratified by anticoagulation indication. Chi-squared tests or Fisher's exact tests were used to assess statistical significance of the differences in VTE, CVA and bleeding rates between anticoagulant cohorts. Differences in times from first prescription date to VTE, CVA and bleeding were analyzed with Kaplan-Meier curves, Log-rank tests, and Cox proportional hazards models. Data were adjusted for age, CHA2DS2-VASc, and Charlson scores. Subgroup analyses were performed for patients with BMI ≥50 kg/m2. Results: Data on 795 patients were collected. In 366 patients with a history of VTE, the rates of recurrent VTE were low and comparable among the apixaban, rivaroxaban and warfarin cohorts [1/47 (2.1%), 3/152 (2%), and 2/167 (1.2%), respectively, p=0.74]. In the subgroup of individuals with BMI ≥50 kg/m2 (n=92), none of the 40 DOAC patients had recurrent VTE. The rates of clinically relevant bleeding, including major bleeding, among VTE patients, were comparable between the three cohorts. Among the 429 patients with AF, stroke rates were also low and similar among anticoagulant cohorts [1/103 (1%) for apixaban, 4/174 (2.3%) for rivaroxaban, and 2/152 (1.3%) for warfarin, p=0.71]. CVAs were similarly rare in patients with BMI ≥50 (1/19 patients on apixaban, 0/37 on rivaroxaban and 1/44 patients on warfarin). In the AF sample, there was no statistically significant difference in the rate of bleeding, including major bleeding, among the 3 cohorts. In an analysis with combined DOAC cohort (apixaban + rivaroxaban vs. warfarin), the recurrent VTE and stroke rates were still low and comparable. There were more major bleeding events in AF patients on warfarin than the combined DOAC cohort (7.9% vs. 2.9%, p=0.02), a finding that became non-significant when adjusted for age, CHA2DS2-VASc, and Charlson scores (p=0.06). The rates of bleeding, including major bleeding, were comparable among the three anticoagulants in both VTE and AF patients with BMI ≥50. Conclusions: Our study is the largest study examining morbidly obese patients on DOACS and provides further evidence of comparable efficacy and safety of the direct oral anti-Xa inhibitors, compared to warfarin, in morbidly obese patients with AF and VTE. Disclosures Kushnir: Janssen: Research Funding. Billett:Bayer: Consultancy; Janssen: Research Funding.

Antiepileptic drugs and suicide-related behavior

BackgroundWe sought to compare trends of suicide-related behavior (SRB) before and after initiation of antiepileptic drug (AED) therapy among AED users (with and without epilepsy) to that of individuals without AED use controlling for sociodemographic characteristics and mental health comorbidity.MethodsWe used national Veterans Health Administration (VHA) data for post-9/11 veterans who received VHA care (2013–2014) without prior AED use. We conducted generalized estimation equation (GEE) analyses, stratified by epilepsy status and type of AED received, to assess the trend of SRB prevalence the year prior to and after the index date (date of first AED prescription/date of first health care encounter for non-AED users) controlling for sociodemographic factors and mental health comorbidity.ResultsThe GEE analysis showed significant curvilinear trends of SRB prevalence over the 24-month study period among the AED users, indicating that the probability of SRB diagnoses increased over time with a peak before the index month and decreased thereafter. Similar patterns were observed among non-AED users, but significantly lower odds for SRB. Among AED users, there were no significant differences by epilepsy status; however, higher SRB prevalence and differential SRB trajectory measures were observed among those who received AEDs with mood-stabilizing action.ConclusionsThe peak of SRB prior to and rapid reduction in SRB after initiation of AED, and the finding that individuals eventually prescribed a mood-stabilizing AED (vs other AED or levetiracetam) had higher odds of SRB, suggests a strong possibility that the relationship of AED and SRB is one of residual confounding.

Cancer patients and primary care prescribed medications: offering insights into symptoms, polypharmacy and multimorbidity

BackgroundNational Cancer Registration and Analysis Service (NCRAS) are responsible for registering data on all cases of cancer. For the first time individual patient level prescribing data is available, offering potential unique insights into treatment and co-morbidity.AimTo investigate the patterns of polypharmacy in cancer patients compared to non-cancer patients.MethodPrimary care prescriptions data (electronic and FP10) is currently available from April to July 2015 inclusive. Unique prescription items were summarised for each registered cancer patient; with an initial focus on opioids. These summaries were broken down by age of the patient at prescription for the most common cancers (invasive breast, colorectal, lung and prostate). Non-cancer patients were used as a comparisonResultsOverall 1,680,764 cancer patients were dispensed prescriptions during the period. On average, patients diagnosed with breast, colorectal, prostate and lung cancers received 7, 8, 8 and 10 unique drugs, respectively, throughout the 4 months. In all cases 2 of these unique drugs were opioids. In comparison, patients not diagnosed with cancer received 4 unique drugs on average: of which 2 were unique opioid drugs. Cancer patients aged 0–39, 40–69 and 70+, at prescription date, received 4, 6 and 8 unique prescriptions respectively compared to 3, 5 and 7, for non-cancer patients.ConclusionThis provides insight into primary care polypharmacy for all cancer patients in England. Analysis is underway to assess the cumulative dosage of unique drugs that patients receive, and the potential use of the data as a marker of polypharmacy/co-morbidity with larger patient level datasets.

Abstract P273: Treatment Patterns Among Vorapaxar New Users in a US Outpatient Clinical Setting

Introduction: Vorapaxar is a once daily oral protease-activated receptor-1 (PAR-1) antagonist for the reduction of thrombotic events in patients with a history of myocardial infarction or peripheral arterial disease. Efficacy and safety was evaluated in a large randomized clinical trial (TRA 2°P TIMI 50), with a median follow-up of 30 months. This is the first descriptive study of vorapaxar treatment patterns in routine clinical practice. Objectives: To evaluate medication adherence and persistence among vorapaxar new users. Methods: Vorapaxar new users ≥18 years of age were identified with an index prescription date between June 2014 and October 2015 with ≥1 years of follow-up through October 2016. The qualifying prescription was identified from Symphony Health’s US outpatient pharmacy claims linked to private practitioner claims and hospital data. Baseline characteristics were assessed using a 1-year look-back prior to the index prescription date. Adherence was defined as a medication possession ratio (MPR) ≥80%, and persistence was defined allowing for up to a 7-day gap in days supply. Sensitivity analysis with 15-day gap to define persistence was performed. Results: The 529 vorapaxar new users included in the analysis were predominantly male (67%), 11% African American and 70% Caucasian, and had a mean (SD) age of 65.2 (10.5) years. At the end of 3, 6, and 12 months, 61%, 45%, and 32%, respectively, of new users were adherent on vorapaxar. A majority (68%) of vorapaxar users were persistent at 3 months, 48% at 6 months, and 29% at 12 months. An additional 10% restarted therapy by the end of the first year after a period of supply interruption. Results of the sensitivity analysis for persistence using 15-day allowable gap were within 1-2% of primary analysis. The median (IQR) time to discontinuation of therapy during the first year was 2.6 (1.2-6.1) months. During the first year, a median (IQR) of 5 (3-9) prescriptions per patient were filled- majority 30 day fills. Conclusions: Medication adherence and persistence of use decreased over time. One-third of patients were adherent and/or persistent at one year. Further research is warranted to understand treatment pattern differences by indication of use and factors affecting adherence and discontinuation.

Real world persistence, adherence and switch-over across anticoagulants in atrial fibrillation-a national population-based study.

ABSTRACTBackgroundThe choice of oral anticoagulant(OAC) for stroke prevention in patients with atrial fibrillation(AF) is now between warfarin and four non-vitamin K anticoagulants(NOACs):dabigatran, rivaroxaban, apixaban and edoxaban. Although discontinuation rates were reported in clinical trials of the NOACs, real-world persistence, adherence and cross-over between therapies are unknown. MethodsPrescription data for OACs in adults with AF between April 2011 and December 2015 were analysed from a representative national primary care database in England(The Health Improvement Network, THIN). Edoxaban was approved for use in the UK in September 2015 and therefore insufficient numbers of prescriptions were available for analysis. Persistence(estimated by gap between prescriptions) and adherence(proportion of days covered, PDC) for OACs were assessed in individuals with AF newly treated with dabigatran, rivaroxaban, apixaban or warfarin with at least 365 days follow-up after the prescription date. For each NOAC, the proportion of cross-over to another OAC was analysed. ResultsAmong 4,354,740 individuals, 118,056 with AF were identified, of which 82,795 had available prescription data for OACs. Of these patients, 78,447 had at least 12 months data: warfarin (n=67781), dabigatran (n=2540), rivaroxaban (n=5666) and apixaban (n=2460). At 1 year, the crude persistence rates were 88.7% (95% CI 88.4-88.9) for warfarin, 59.1% (57.2-61.0) for dabigatran, 64.7% (63.4-65.9) for rivaroxaban and 67.0% (65.1-68.9) for apixaban. Persistence was significantly lower than in the clinical trials and was lower for NOACs than warfarin. The adherence rates (PDC>80%) were 87.5% (CI 87.3,87.6) for warfarin, 83.5% (CI 82.3,84.8) for dabigatran, 84.1% (CI 83.1,85.1) for rivaroxaban and 83.6% (CI 81.6,85.5) for apixaban. The proportion of NOAC users crossing over to another NOAC and to warfarin were 12.1% and 7.3% for dabigatran, 3.4% and 3.4% for rivaroxaban, and 1.9% and 1.5% for apixaban respectively. ConclusionsIn a large English population, NOACs exhibited lower persistence rates than in clinical trials, warranting further analyses of side effect profile and acceptability of OACs. Routinely collected data can be used to measure real-world persistence and adherence which are important in future studies of comparative effectiveness.

Potential Obstacles in the Acquisition of Oral Anticancer Medications

Purpose: To determine the amount of time elapsed between prescriber order and patient receiving oral anticancer medication. Patients and Methods: Adult patients with a diagnosis of cancer were prospectively identified in three outpatient oncology clinics when oral anticancer agents were prescribed during a 4-month observation period. For each patient, time to obtain medication was analyzed by the following time points: date of prescription, date of submission to insurance, date prior authorization was obtained, date financial assistance was received, date prescription was processed by pharmacy, and date patient received medication. Out-of-pocket cost and time spent by clinic staff to facilitate the medication acquisition process were recorded. Results: Thirty-four patients were prescribed oral anticancer medication during the data collection period. For the 27 patients who were eligible for the primary end point, medication acquisition required a median of 10 days (range, 3 to 28 days). Overall, the rate-limiting step for medication acquisition was processing by the pharmacy, with a median of 6 days (range, 1 to 27 days). Most patients’ prescription insurance plan covered a portion of medication cost, and the majority of patients considered their out-of-pocket expense to be affordable. Clinic staff spent a median of 2 hours per prescription to facilitate medication acquisition. Conclusion: Patients may encounter process barriers in acquiring oral therapy, particularly because of pharmacy processing time, as well as high copays. Time to treatment initiation may have implications for patients’ clinical outcomes. Adequate staff with dedicated time to facilitate this process should be used in the ambulatory oncology practice setting.

Abstract 17609: Comparison of All-cause and Bleeding-related Hospitalizations Among Non-valvular Atrial Fibrillation Patients Receiving Oral Anticoagulants

To compare the risk of hospitalization among non-valvular atrial fibrillation (NVAF) patients newly initiated with an oral anticoagulant (OAC): apixaban, dabigatran, rivaroxaban, or warfarin. Retrospective cohort study using Humana Medicare Advantage data from 7/1/2009 - 9/30/2014. NVAF patients ≥18 years receiving one OAC on the index date with 6 months continuous enrollment prior to index prescription date and 3 months post-index were eligible. Hospitalizations were identified by standard codes for inpatient admission. Bleeding-related hospitalizations required an additional code for major/clinically relevant non-major (CRNM) bleeding. A cox proportional hazards model was used to estimate the hazard ratios (HR) of hospitalizations adjusted for age, sex, region, comorbidities and comedications. Adherence for each OAC was also calculated using a proportion of days covered approach to understand medication taking behaviors. Among the 53,168 patients initiated on an OAC, 2,028 (3.8%) apixaban, 5,644 (10.6%) dabigatran, 7,667 (14.4%) rivaroxaban and 37,829 (71.1%) warfarin. Patients in apixaban cohort were older (mean 75.5 years, P <0.05) with higher mean CHA 2 DS 2- VASc score (P <0.05). Abixaban patients had a higher mean HAS-BLED score vs. dabigatran (P <0.0001), lower mean score vs. warfarin (P <0.0001) and did not differ significantly vs. rivaroxaban (P =0.46). Patients receiving apixaban had a significantly lower risk for all-cause hospitalization across cohorts, and a sig. lower risk for bleeding-related hospitalization vs. patients receiving rivaroxaban or warfarin (Table). Adherence ranged from 87.8% to 90.4% across cohorts. In a real-world setting, initiation with apixaban was associated with a significantly lower risk for all-cause hospitalization, and a significantly lower risk of bleeding-related hospitalization compared to rivaroxaban or warfarin. Table: Adjusted Hazard Ratios of All-cause and Bleeding-related Hospitalizations

Oral oncolytics: Patient-monitoring improvements in private practice.

215 Background: The use of oral oncolytics is becoming more common. These drugs have their own unique challenges in managing patient initiation, monitoring side effects and adherence. Methods: We conducted a baseline chart audit of patients prescribed oral oncolytics in our private oncology practice followed by a quality improvement program and subsequent reassessment. Information obtained included: prescription date, actual start date and any documented problems with the oral therapy. The baseline audit included patients from may of 2011 to July 2013. Subsequently we joined the Michigan oncology quality consortium’s oral chemotherapy collaborative and initiated the following: office procedures for identification of all patients on oral therapy, use of the Edmonton Symptoms assessment system (ESAS), and a self-care management education program including patient self-monitoring of symptoms with recommended initial treatments. A postintervention audit was conducted from August 2013 to March 2014. Results: We identified 25 patients in the first time period and 13 in the second. In the first time period we found only 13 of the 25 patients had an actual start date documented, and of these 13, 10 had a >/=4 week delay prior to starting therapy, with 3/13 having a 2-4 week delay prior to start of therapy. 12 of the 25 patients discontinued their drug within the first month due to side effects without consulting their physician. After participating in the quality initiative, we identified only one patient without a documented start date, only 1/13 that had a > 4 week delay from prescription date to starting the drug, with 12/13 having a less than 2 week lapse. We also found that there were no patients who discontinued the drug and only one dose reduction as directed by the physician. Conclusions: The introduction of new office procedures to easily identify all patients on oral therapy and improved patient management of symptoms at home with the use of self-care guidelines, and in the office with use of ESAS contributed to greater adherence to oral chemotherapy regimens.