Prescription Drug Shortages: Implications for Public Health and Potential Solutions

Prescription drug shortages have reached critical levels in the United States and represent a significant threat to healthcare quality and patient safety. The increase in drug shortages has been attributed to a variety of factors, although some underlying themes prevail, primarily quality problems at manufacturing facilities. Market factors also play a significant role. Sterile generic injectable medications have been disproportionately impacted by drug shortages. This thesis is intended to explore the impacts of drug shortages across a wide range of specialties, care settings, and populations. This work will describe trends in drug shortages over time and the potential implications for patient care and public health. It also addresses current and proposed initiatives to mitigate this public health threat

Opioid Administration and Prescribing in Older Adults in U.S. Emergency Departments (2005-2015).

Introduction: We assess trends in opioid administration and prescribing from 2005-2015 in older adults in United States (U.S.) emergency departments (ED). Methods: We analyzed data from the National Hospital Ambulatory Medical Care Survey (NHAMCS) survey from 2005 to 2015. ED visits for painful conditions were selected and stratified by age (18-64, 65-74, 75-84, ≥ 85 years). We analyzed trends in opioid administration in the ED and prescribing at discharge to encounters ≥ 65 and assessed predictors of use using survey-weighted chi-square tests and logistic regression. Trends in the use of five commonly prescribed opioids were also explored. Results: Opioid administration in the ED and prescribing at discharge for encounters with patients ≥ 65 years fell overall, but not significantly. By contrast, opioid administration in the ED and prescribing at discharge significantly declined for adult encounters 18-64 by 20% and 32%, respectively. A similar proportion of adult encounters ≥ 65 were administered opioids in the ED as 18-64, but adult encounters ≥ 85 had the lowest rates of administration. A smaller proportion of adult encounters ≥ 65 years with painful conditions were prescribed opioids at discharge compared to Conclusion: From 2005-15, 1 in 4 to 1 in 10 ED patients with painful conditions were administered or prescribed an opioid in U.S. EDs. Opioids prescribing increased from 2005-11 and then declined from 2012-15, more so among visits in the 18-64 age group compared to ≥ 65 years. Opioid administrating demonstrated a gradual rise and decline in all adult age groups. Age consistently appears to be an important consideration, where opioid prescribing declines with advancing age. Given the nationwide opioid crisis, ED providers should remain vigilant in limiting opioids, particularly in older adults who are at higher risk for adverse effects

Magnesium Depletion in Patients Treated with Therapeutic Hypothermia After Cardiac Arrest

Magnesium (Mg2+) depletion can have detrimental effects in postcardiac arrest patients through multiple potential mechanisms. Therapeutic hypothermia (TH) produces a Mg2+ diuresis, but the effects of postcardiac arrest TH on serum Mg2+ levels in patients with postcardiac arrest syndrome (PCAS) are yet to be systematically quantified. We conducted a retrospective chart review of 119 consecutive comatose PCAS patients treated with TH between 2005 and 2010 and compared them to 33 matched historic controls (HCs) seen at the same institution between 2002 and 2005 who were not treated with TH. We abstracted data from the first 96 hours postarrest, including date, time, and value of serum Mg2+ levels and date, time, and amount of Mg2+ repletion, along with outcomes at discharge. The median Mg2+ level of TH patients was 2.0?mg/dL [interquartile range (IQR), 1.9?2.2?mg/dL] (0.82 mmol/L [IQR, 0.78?0.90 mmol/L]) versus 2.2?mg/dL [IQR, 1.9?2.4?mg/dL] (0.90 mmol/L [IQR, 0.82?0.99 mmol/L]) (p=0.2) in HCs. In addition, 42.9% (520/1214) of Mg2+ levels in TH patients versus 31.9% (43/135) (p=0.014) in HC patients were below 2.0?mg/dL [0.82 mmol/L]. The average number of times the Mg2+ level was checked in TH patients was 10.2 (range 1?18) versus 4.1 (range 1?10) in HCs. The TH patients were more likely to receive supplemental Mg2+ than HCs (81.5% [97/119] vs. 27.3% [9/33] [p<0.01]). The mean supplemental Mg2+ dose was 1.9?g for TH patients versus 0.5?g for HC patients. Mortality in patients treated with TH was 53.1% (60/113) versus 78.6% (22/28) (p=0.014) in HCs. Low serum Mg2+ levels with subsequent Mg2+ supplementation were more common in comatose patients with PCAS treated with TH compared to normothermic HC patients. The effect of untreated hypomagnesemia on postcardiac arrest outcomes remains to be determined.Peer Reviewedhttps://deepblue.lib.umich.edu/bitstream/2027.42/140255/1/ther.2014.0012.pd

Epidemiology of Alcohol-Related Visits to United States Emergency Departments, 2001-2010

Background: Alcohol intoxication accounts for approximately 1.5% of all emergency department (ED) visits in the United States. In the context of a strained ED system, understanding the epidemiology of alcohol-related ED visits at a national level represents an important area of research. Objectives: To characterize trends in alcohol-related visits to U.S. EDs from 2001 to 2011. Methods: A retrospective review of data on national ED visits among patients aged 18 years or older between 2001 and 2011 was conducted using the National Hospital Ambulatory Medical Care Survey (NHAMCS). Alcohol intoxication was defined by either a diagnosis of idiosyncratic alcohol intoxication, acute alcohol intoxication, alcohol abuse, or ethyl alcohol, or by a reason for visit coded in NHAMCS as alcohol-related problems, adverse effects of alcohol, alcoholism, or alcohol detoxification. Demographic characteristics were examined for trends in alcohol-related visits. Trends in resource use were examined. ED length of stay (LOS) was assessed for changes across the study period. We also assessed trends in the total hours spent on ED care for alcohol-related complaints at a national level. Data were grouped into two-year sets to improve statistical power. Proportions were compared using survey-weighted chi square tests, while tests for trend were assessed using survey-weighted logistic regression. Results: Between 2001-02 and 2010-11, alcohol-related visits increased from 2,459,748 to 3,856,346 (p=0.049). There was no notable increase in proportion of visits across all tested demographic and hospital-level categories. The use of advanced imaging increased 232.2% over the study period (p\u3c0.001), while the mean number of medications provided increased from 1.41 to 1.75 (p=0.016). Overall LOS increased 16.1% (p=0.028), while LOS among admitted patients increased 24.9% (p=0.076). Total alcohol-related hours spent in EDs nationwide increased from 5.6 million in 2001 to 11.6 million in 2010, an increase of 108.5% (p\u3c0.001) compared with an increase in overall ED hours of 54.0% (p\u3c0.001). Conclusion: Alcohol-related ED visits are increasing at a greater rate than overall ED visits and represent a growing burden in length of stay and resource use