Appropriateness of Outpatient Antibiotic Use in Seniors across Two Canadian Provinces

Antimicrobials are among the most prescribed medications in Canada, with over 90% of antibiotics prescribed in outpatient settings. Seniors prescribed antimicrobials are particularly vulnerable to adverse drug events and antimicrobial resistance. The extent of inappropriate antibiotic prescribing in outpatient Canadian medical practice, and the potential long-term trends in this practice, are unknown. This study is the first in Canada to examine prescribing quality across two large-scale provincial healthcare systems to compare both quantity and quality of outpatient antibiotic use in seniors. Population-based analyses using administrative health databases were conducted in British Columbia (BC) and Ontario (ON), and all outpatient, oral antimicrobials dispensed to seniors (≥65 years) from 1 January 2000 to 31 December 2018 were identified. Antimicrobials were linked to an indication using a 3-tiered hierarchy. Tier 1 indications, which always require antibiotics, were given priority, followed by Tier 2 indications that sometimes require antibiotics, then Tier 3, which never require antibiotics. Prescription rates were calculated per 1000 population, and trends were examined overall, by drug class, and by patient demographics. Prescribing remained steady in both provinces, with 11,166,401 prescriptions dispensed overall in BC, and 27,656,014 overall in ON. BC prescribed at slightly elevated rates (range: 790 to 930 per 1000 residents), in comparison to ON (range: 745 to 785 per 1000 residents), throughout the study period. For both provinces, a Tier 3 diagnosis was the most common reason for antibiotic use, accounting for 50% of all indication-associated antibiotic prescribing. Although Tier 3 indications remained the most prescribed-for diagnoses throughout the study period, a declining trend over time is encouraging, with much room for improvement remaining. Elevated prescribing to seniors continues across Canadian outpatient settings, and prescribing quality is of high concern, with 50% of all antimicrobials prescribed inappropriately for common infections that do not require antimicrobials.

Economic Burden of Pneumococcal Disease in Individuals Aged 15 Years and Older in the Liguria Region of Italy

Despite the availability of vaccines against Streptococcus pneumoniae, the global incidence and economic cost of pneumococcal disease (PD) among adults is still high. This retrospective cohort analysis estimated the cost of emergency department (ED) visits/hospitalizations associated with non-invasive pneumonia and invasive pneumococcal disease among individuals ≥15 years of age in the Liguria region of Italy during 2012–2018. Data from the Liguria Region Administrative Health Databases and the Ligurian Chronic Condition Data Warehouse were used, including hospital admission date, length of stay, discharge date, outpatient visits, and laboratory/imaging procedures. A ≥30-day gap between two events defined a new episode, and patients with ≥1 ED or inpatient claim for PD were identified. The total mean annual number of hospitalizations for PD was 13,450, costing ~€49 million per year. Pneumonia accounted for the majority of hospitalization costs. The median annual cost of hospitalization for all-cause pneumonia was €38,416,440 (per-capita cost: €26.78) and was €30,353,928 (per-capita cost: €20.88) for pneumococcal and unspecified pneumonia. The total number and associated costs of ED visits/hospitalizations generally increased over the study period. PD still incurs high economic costs in adults in the Liguria region of Italy.

143. Antibiotic Use for Common Infections in British Columbia and Ontario: A Review of Outpatient Prescribing to Seniors from 2000 – 2018

Background Antimicrobials remain among the most prescribed medications in Canada, with over 90% prescribed in outpatient settings. Older adults (aged ≥65 years) prescribed antimicrobials are particularly vulnerable to adverse drug events and antimicrobial resistance. This study compared annual rates of indication-associated, outpatient prescribing to seniors across two Canadian provinces. Methods All outpatient, oral antimicrobials dispensed to older adults (≥65 years) were identified from administrative health databases, from 2000 to 2018. Antimicrobials were limited to outpatient use only and linked to an indication using a 3-tiered diagnostic hierarchy. When possible, a record of dispensation was matched to a tier 1 indication (always require antibiotics) first. In the absence of a tier 1 indication, priority was given to tier 2 (sometimes require antibiotics), then 3 (never require antibiotics). Prescription rates were calculated per 1000 population, and trends were examined overall, by drug class, and patient demographics. Results Our study included over 18 million individuals (aged ≥65 years) with a total of 23,773,552 antibiotic prescriptions issued to seniors, for common infections. In both provinces, prescribing for tier 1 diagnoses increased over the study period (BC: 44%; ON: 28%). Urinary tract infections accounted for most prescriptions within this tier (ON: 89 prescriptions/1000, BC: 129 prescriptions/1000 population by 2018). Pneumonia-associated prescribing increased by roughly 10% in both provinces. In any given study year, for both provinces, tier 3 diagnosis was the most common reason for antibiotic use, accounting for 50% of all indication-associated antibiotic prescribing. As diagnoses within this tier do not warrant prescribing all antibiotics issued are therefore inappropriate prescriptions. Figure 1. Rates of indication-associated antibiotic use in Canadian seniors, from 2000 to 2018. Conclusion Elevated prescribing to seniors continues across Canadian outpatient settings. Antibiotic prescribing remains an issue of high concern with 50% of all antimicrobials prescribed to seniors, for common infections, used inappropriately. Disclosures All Authors: No reported disclosures

1361. Actinotignum schaalii an Under-recognized Cause of Infections: A Case Series in Calgary from 2012 - 2020

Background Actinotignum schaalii is a gram-positive rod that is a fastidious commensal of the urogenital tract. Infections with A. schaalii are underdiagnosed previously because phenotypic methods fail to identify it. Both MALDI-TOF mass spectrometry and 16S rRNA sequencing allow definitive identification of this opportunistic emerging pathogen. A. schaalii is an infrequent but important cause of UTIs in the elderly, particularly with urological abnormalities. The spectrum of invasive disease caused by A. schaalii is not well characterized; however, it has been isolated in severe infections including necrotizing skin and soft tissue infections, bacteremia, osteomyelitis, and endocarditis. We used a population-based approach to characterize and describe the clinical and microbiological features of invasive A. schaalii infections in our region. Methods All adult and pediatric cases enrolled had microbiological isolates of Actinotignum schaalii recovered from blood cultures, sterile fluids and tissue cultures from Jan 2012 to Dec 2020 by APL, a regional centralized microbiology laboratory serving the Calgary Zone in Alberta, Canada. Clinical data were retrieved and linked from administrative health databases, chart review and the laboratory information system. Standard descriptive statistics were used. Results We identified 84 unique A. schaalii infections, 35 were from bloodstream, 32 soft tissue, 7 post-operative infections. Median age and Charslon comorbidity score was higher in BSI. 54.3% of patient with BSI had a genitourinary pathology, with 51.4% caused by a complicated urinary infection, while soft and skin tissue infections caused 65.3% of non-BSI. Using EUCAST MIC cut-offs, 48% and 100% of the isolates were resistant to clindamycin and metronidazole, respectively. In contrast, all specimens were susceptible to penicillin. Hospitalization and 90-days mortality were higher in the BSI group. Conclusion A. schaalii is an anaerobic opportunistic pathogen that can cause life-threatening invasive infections, particularly in older adults with underlying genitourinary pathology. BSI were associated with higher rates of hospitalization and mortality. In contrast, patients with A. schaalii isolated from cutaneous sources were younger and had better clinical outcomes. Disclosures All Authors: No reported disclosures

Measuring Substance-Related Disorders Using Canadian Administrative Health Databanks: Interprovincial Comparisons of Recorded Diagnostic Rates, Incidence Proportions and Mortality Rate Ratios

Context Assessing temporal changes in the recorded diagnostic rates, incidence proportions, and health outcomes of substance-related disorders (SRD) can inform public health policymakers in reducing harms associated with alcohol and other drugs. Objective To report the annual and cumulative recorded diagnostic rates and incidence proportions of SRD, as well as mortality rate ratios (MRRs) by cause of death among this group in Canada, according to their province of residence. Methods Analyses were performed on linked administrative health databases (AHD; physician claims, hospitalizations, and vital statistics) in five Canadian provinces (Alberta, Manitoba, Ontario, Québec, and Nova Scotia). Canadians 12 years and older and registered for their provincial healthcare coverage were included. The International Classification of Diseases (ICD-9 or ICD-10 codes) was used for case identification of SRD from April 2001 to March 2018. Results During the study period, the annual recorded SRD diagnostic rates increased in Alberta (2001–2002: 8.0‰; 2017–2018: 12.8‰), Ontario (2001–2002: 11.5‰; 2017–2018: 14.4‰), and Nova Scotia (2001–2002: 6.4‰; 2017–2018: 12.7‰), but remained stable in Manitoba (2001–2002: 5.5‰; 2017–2018: 5.4‰) and Québec (2001–2002 and 2017–2018: 7.5‰). Cumulative recorded SRD diagnostic rates increased steadily for all provinces. Recorded incidence proportions increased significantly in Alberta (2001–2002: 4.5‰; 2017–2018: 5.0‰) and Nova Scotia (2001–2002: 3.3‰; 2017–2018: 3.8‰), but significantly decreased in Ontario (2001–2002: 6.2‰; 2017–2018: 4.7‰), Québec (2001–2002: 4.1‰; 2017–2018: 3.2‰) and Manitoba (2001–2002: 2.7‰; 2017–2018: 2.0‰). For almost all causes of death, a higher MRR was found among individuals with recorded SRD than in the general population. The causes of death in 2015–2016 with the highest MRR for SRD individuals were SRD, suicide, and non-suicide trauma in Alberta, Ontario, Manitoba, and Québec. Discussion Linked AHD covering almost the entire population can be useful to monitor the medical service trends of SRD and, therefore, guide health services planning in Canadian provinces.

Thallium Contamination of Drinking Water: Health Implications in a Residential Cohort Study in Tuscany (Italy)

In 2014–2015, concentrations of thallium above the recommended reference value (EPA: 2 µg/L) were measured in some parts of the drinking water distribution system in the municipality of Pietrasanta (Tuscany, Italy). An extensive campaign of water samples and human biomonitoring surveys were implemented to quantify the exposure of population. A residential cohort epidemiological study was carried out on the population of the municipality of Pietrasanta, aimed at comparing the health status of residents in the areas affected by thallium contamination with residents living in the rest of the municipality. Cohort included people residing in the municipality of Pietrasanta from 1 January 2000 to 31 December 2015. Residence addresses were georeferenced and each subject living in one of the three contaminated areas were defined as exposed. Mortality, hospital discharge data and adverse pregnancy outcomes were taken from administrative health databases. Cox proportional hazard models and logistic models were used to test the association between thallium exposure and health outcome. This study did not show any excess of risk in terms of mortality and hospitalization in the population residing in the areas served by thallium-contaminated aqueduct branches, compared to the rest of the not contaminated area. Increased risks for low birth weight (OR = 1.43 95% CI 0.91–2.25) and pre-term birth (OR = 1.40 95% CI 0.82–2.37) were observed. In view of the paucity of epidemiological studies on thallium, this study is an important contribution to the state of knowledge of the health effects of chronic exposures to low concentrations of thallium.

Trends in oral corticosteroids use in severe asthma: a 14-year population-based study

Background Oral corticosteroids are important components of pharmacotherapy in severe asthma. Our objective was to describe the extent, trends, and factors associated with exposure to oral corticosteroids (OCS) in a severe asthma cohort. Methods We used administrative health databases of British Columbia, Canada (2000–2014) and validated algorithms to retrospectively create a cohort of severe asthma patients. Exposure to OCS within each year of follow-up was measured in two ways: maintenance use as receiving on average ≥ 2.5 mg/day (prednisone-equivalent) OCS, and episodic use as the number of distinct episodes of OCS exposure for up to 14 days. Trends and factors associated with exposure on three time axes (calendar year, age, and time since diagnosis) were evaluated using Poisson regression. Results 21,144 patients (55.4% female; mean entry age 28.7) contributed 40,803 follow-up years, in 8.2% of which OCS was used as maintenance therapy. Maintenance OCS use declined by 3.8%/calendar year (p < 0.001). The average number of episodes of OCS use was 0.89/year, which increased by 1.1%/calendar year (p < 0.001). Trends remained significant for both exposure types in adjusted analyses. Both maintenance and episodic use increased by age and time since diagnosis. Conclusions This population-based study documented a secular downward trend in maintenance OCS use in a period before widespread use of biologics. This might have been responsible for a higher rate of exacerbations that required episodic OCS therapy. Such trends in OCS use might be due to changes in the epidemiology of severe asthma, or changes in patient and provider preferences over time.

Validation of an Algorithm to Detect Multiple Sclerosis Cases in Administrative Health Databases in Piedmont (Italy): An Application to the Estimate of Prevalence by Age and Urbanization Level

<b><i>Introduction:</i></b> Italy is considered a high-risk country for multiple sclerosis (MS). Exploiting electronic health archives (EHAs) is highly useful to continuously monitoring the prevalence of the disease, as well as the care delivered to patients and its outcomes. The aim of this study was to validate an EHA-based algorithm to identify MS patients, suitable for epidemiological purposes, and to estimate MS prevalence in Piedmont (North Italy). <b><i>Methods:</i></b> MS cases were identified, in the period between January 1, 2012 and December 31, 2017, linking data from 4 different sources: hospital discharges, drug prescriptions, exemptions from co-payment to health care, and long-term care facilities. Sensitivity of the algorithm was tested through record linkage with a cohort of 656 neurologist-confirmed MS cases; specificity was tested with a cohort of 2,966,293 residents presumably not affected by MS. Undercount was estimated by a capture-recapture method. We calculated crude, and age- and gender-specific prevalence. We also calculated age-adjusted prevalence by level of urbanization of the municipality of residence. <b><i>Results:</i></b> On December 31, 2017, the algorithm identified 8,850 MS cases. Sensitivity was 95.9%, specificity was 99.97%, and the estimated completeness of ascertainment was 91.9%. The overall prevalence, adjusted for undercount, was 152 per 100,000 among men and 286 among women; it increased with increasing age and reached its peak value in the 45- to 54-year class, followed by a progressive reduction. The age-adjusted prevalence of residents in cities was 15% higher than in those living in the countryside. <b><i>Discussion/Conclusion:</i></b> We validated an algorithm based on EHAs to identify cases of MS for epidemiological use. The prevalence of MS, adjusted for undercount, was among the highest in Italy. We also found that the prevalence was higher in highly urbanized areas.

Spatial Analysis of Healthcare Offer and Request for Older People Aged 65 Years and Over in Quebec

With years, the health-needs of an individual become numerous and more complex, resulting in the requirement of an even more appropriate offer of health services. However, it is known that different factors make the services and the request of the population to health care unequally, especially the interregional variations. These are represented by a gap between the offer of healthcare and the need of the populations. The aim of this study was 1) to map the relationship between the location of the healthcare services in Quebec and population aged 65 years and over, and 2) to identify the characteristics related to the geographic variations in access to healthcare. We used data from “statcan.gc.ca”, “donneesquebec.ca” and “msss.gouv.qc.ca” regarding the facilities, their capacity, their services, and the populations’ characteristics. Analyses were performed on QGIS and R software. As expected, our results showed that there is a gap between the healthcare needs and the services: older people need a large amount of diverse services which are not always provided by secluded areas. Moreover, it also appeared that the deprivation index is related to the offer of health care. As this project takes part in a global project studying the health care trajectories of older people in Quebec using their administrative health databases, those findings will help better understand the impact of the geographic factors for the interregional variations of healthcare.

Trends in oral corticosteroids use in severe asthma: a 14-year population-based study from Canada

Background: Oral corticosteroids are important components of pharmacotherapy in severe asthma. Our objective was to describe the extent, trends, and factors associated with exposure to oral corticosteroids (OCS) in a severe asthma cohort.Methods: We used administrative health databases of British Columbia, Canada (2000–2014) and validated algorithms to retrospectively create a cohort of severe asthma patients. Exposure to OCS within each year of follow-up was measured in two ways: maintenance use as receiving on average ≥2.5 mg/day (prednisone-equivalent) OCS, and episodic use as the number of distinct episodes of OCS exposure for up to 14 days. Trends and factors associated with exposure on three time axes (calendar year, age, and time since diagnosis) were evaluated using Poisson regression.Results: 21,144 patients (55.4% female; mean entry age 28.7) contributed 40,803 follow-up years, in 8.2% of which OCS was used as maintenance therapy. Maintenance OCS use declined by 3.8%/calendar year (p<0.001). The average number of episodes of OCS use was 0.89/year, which increased by 1.1%/calendar year (p<0.001). Trends remained significant for both exposure types in adjusted analyses. Both maintenance and episodic use increased by age and time since diagnosis. Conclusions: This population-based study documented a secular downward trend in maintenance OCS use in a period before widespread use of biologics. This might have been responsible for a higher rate of exacerbations that required episodic OCS therapy. Such trends in OCS use might be due to changes in the epidemiology of severe asthma, or changes in patient and provider preferences over time.