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Biomedical subjects

D M Kirking

Publications and source records attributed to D M Kirking.

At least 37 records · Page 2Linked to original sources
PubMed1993

Assessing the quality of pharmaceutical care. II. Application of concepts of quality assessment from medical care.

OBJECTIVE: To present a framework that facilitates quality assessment of pharmaceutical care (PC) so that the profession and the public may identify pharmacists in ambulatory settings who provide quality care in all aspects of the their practices. DATA SOURCES: A MEDLINE search augmented by a review of International Pharmacy Abstracts was used to identify pertinent quality assessment and pharmacy practice literature; indexing terms included quality assurance, healthcare, pharmacists, community pharmacy services, ambulatory, pharmacy, and process and outcome assessment. STUDY SELECTION: All identified quality assessments of community pharmacy practice were considered. Studies that documented the effectiveness of specific pharmacist activities and patient satisfaction were also included. DATA EXTRACTION: The literature was independently reviewed by the primary author. DATA SYNTHESIS: The structure-process-outcome paradigm is presented as a framework for quality assessment of PC. Structure should be assessed at periodic intervals because it identifies the potential for the provision of quality care. Process, the care that pharmacists provide, must be documented and linked to outcomes before either structure or process can be used to make inferences about the quality of PC. Technical and interpersonal processes should be examined. Outcomes require an interdisciplinary approach that not only considers other medical care inputs but also recognizes the psychologic, economic, and social factors that affect health status and quality of life. Process and outcome must both be assessed to distinguish the contribution of pharmacists from that of other healthcare providers. Examples of criteria are provided and a model to integrate PC within the healthcare system is discussed. CONCLUSIONS: It is pharmacists' duty to ensure that patients receive an acceptable level of PC. The structure-process-outcome paradigm provides a framework to identify and link pharmacists' processes with patients' outcomes.

Ambulatory Care↗
PubMed1993

Assessing physician choice of nonsteroidal antiinflammatory drugs in a health maintenance organization.

OBJECTIVE: To develop a categorization scheme for grouping various nonsteroidal antiinflammatory drugs (NSAIDs) by relative safety; to develop a method to quantify the appropriateness of the initial and subsequent choices of NSAID therapy; to assess whether NSAID prescribing was consistent with the developed criteria; to examine the cost of inappropriate, acute NSAID use as defined by the established criteria. DESIGN: Retrospective drug utilization review focusing on NSAIDs. SETTING/PARTICIPANTS: Members aged > or = 18 years of a 40,000-person southeastern Michigan health maintenance organization. MAIN OUTCOME MEASURES: (1) Appropriateness of therapy using a four-level safety classification system for the NSAIDs developed by a consensus process; criteria based on safety under the assumption that any particular NSAID is equally likely to be effective when dosed appropriately; (2) evaluation of progression of NSAID therapy using the NSAID Therapy Progression Formula. RESULTS: For acute patients, almost half of the prescriptions were for ibuprofen and 33 percent were for naproxen. Ibuprofen usage accounted for 16 percent of total NSAID cost and naproxen agents accounted for over 50 percent of that cost. Potential cost savings of approximately $82,000 probably would have occurred had a 50 percent interchange rate for ibuprofen been acceptable. For chronic patients, 85 percent were treated with one or two NSAIDs; treatments were of reasonable high quality when compared by safety profiles. There was low use of ibuprofen in patients who only received one NSAID. CONCLUSIONS: NSAID usage assessment in a large population was achieved by developing a classification and scoring system based on NSAID safety; in this population, prescribing patterns were generally consistent with established criteria; however, when considering cost, improvement in initial NSAID selection for acute patients was possible.

Adult↗
PubMed1993

Evaluation of unclaimed prescriptions in an ambulatory care pharmacy.

Unclaimed prescriptions, that is, those filled but not obtained by the patient, may influence patient care and pharmacy operations. The authors' objectives were to 1) describe characteristics of unclaimed prescriptions and the patients for whom these prescriptions were written, and 2) compare and contrast characteristics of prescriptions never dispensed with those that were eventually dispensed. During the 8-week study, 180 patients with 224 unclaimed prescriptions were identified at the University of Michigan Hospital's Ambulatory Care Pharmacy. The most frequent categories of unclaimed prescriptions were skin/mucous membrane, central nervous system, and anti-infective medications. In 25.9% of cases of unclaimed prescriptions, they were telephoned in by a healthcare professional as new prescriptions. Overall, 64.3% were new, rather than refill, prescriptions. Approximately two thirds of the unclaimed prescriptions were eventually dispensed. Of the characteristics evaluated for differences between unclaimed prescriptions eventually dispensed and those never dispensed, only new versus refill prescriptions and class of medication were significantly different. Most unclaimed prescriptions were eventually dispensed after a delay. However, the types of medications involved suggest that these delays from initially unclaimed prescriptions could have resulted in problems.

Adult↗
PubMed1992

Information systems for evaluating the quality of prescribing.

OBJECTIVE: An important purpose of drug usage evaluation (DUE) is to provide feedback to physicians on population-based prescribing patterns and problems. This article has four objectives: (1) to outline prescribing information requirements for a computerized information system in terms of the variables needed for DUE, (2) to describe existing computerized information systems that collect and organize prescribing data, (3) to assess existing systems in terms of their capacity to provide the requirements outlined in our first objective, and (4) to suggest design changes to existing systems that would improve the DUE process. ANALYSIS: There are several existing DUE information systems that have some capacity to evaluate the quality of prescribing in specific populations (e.g., veterans, public and private insured groups, hospital service areas). Shortcomings of most DUE information systems include patient identification problems, defects in database design, and lack of software to identify prescribing problems and perform statistical analysis. CONCLUSIONS: DUE information systems could be used and upgraded to enable physicians to develop more rational prescribing rules from population data that would improve the quality of prescribing.

Drug Prescriptions↗
PubMed1992

Impact of consumer fees on drug utilisation.

A review of research on consumer fees for drugs and drug utilisation suggests that the demand for drugs tends to be quite insensitive to consumer fees. Although higher consumer fees are associated with slightly reduced rates of drug utilisation, use of most other medical services is not meaningfully affected and health status has not been shown to be adversely affected. The larger impact of consumer fees demonstrated in the published literature is to shift drug costs from third parties to consumers. Since much of the literature is limited to insurance programmes with quite small consumer fees, the generalisability of results may be limited. Ability-to-pay and health needs may also be important considerations in the relationship between use and fees for particular drugs.

Aged↗
PubMed1991

Evaluation of direct pharmacist intervention on conversion from parenteral to oral histamine H2-receptor antagonist therapy.

A program in which pharmacists were authorized to change parenteral histamine H2-receptor antagonist (H2RA) therapy to the oral route without first contacting the prescriber was evaluated on cost and appropriateness of use of the parenteral route. Parenteral therapy was received by 264 and 244 patients in the study and comparison groups, respectively. Length of parenteral H2RA therapy was less in the study group (4.8 vs. 7.5 d) as was length of total (parenteral + oral) therapy (8.4 vs. 12.1 d). Parenteral H2RA drug acquisition savings were $6225 in the six-week study period or $53,950 when annualized. Decreased oral therapy contributed additional savings. There was a significant decrease in the number of inappropriate parenteral doses of ranitidine per patient, the drug used in more than 80 percent of the patients. In addition to the direct effect of pharmacists' interventions, there appeared to be an indirect effect of the program, as physicians initiated route of administration changes on their own.

Administration, Oral↗
PubMed1991

Physician opinion of pharmacist-initiated change from injectable to oral administration of histamine H2-receptor antagonists.

Physicians' knowledge of dosage and cost differences between injectable and oral histamine H2-receptor antagonists (HRAs) and attitudes toward pharmacist-initiated route conversion of HRAs were assessed. A questionnaire was mailed to 491 physicians two months before implementation of a hospital program that allowed pharmacists to use preapproved guidelines to directly change the route of HRA administration. A similar questionnaire was sent to 488 physicians after five months of program operation. The response rate was 36.0% and 37.5% for the first and second surveys, respectively. In both surveys, almost half of the respondents gave incorrect answers or did not know whether dosage should be altered when HRA route is changed, and about 60% underestimated the relative cost of injectable HRAs. Among respondents who were aware of the program, 28% preferred direct pharmacist intervention; 15% of respondents who were unaware of the program had the same preference. Physicians generally responded positively to statements regarding the acceptability of the program and thought that the pharmacist's role in route conversion was appropriate. Many physicians were ignorant of differences in dosage and cost between injectable and oral HRAs. They generally supported allowing pharmacists to change the route of HRA administration from injectable to oral.

Administration, Oral↗
PubMed1990

Choices in prescription-drug benefit programs: mail versus community pharmacy services.

Pharmaceutical price increases and greater coverage of outpatient prescription medications have stimulated interest in containing drug benefit-program costs. While mail pharmacy services (MPS) may achieve savings through volume purchasing, high usage of generic drugs, and dispensing larger quantities of medication per prescription, efforts are also underway to adapt community-pharmacy-based services to keep costs down in these areas. No controlled studies document a difference in quality between the two types of services. Third-party administrators and benefit managers need to consider factors such as providing information to patients, monitoring drug therapy, dispensing patients' correct medication, and cost-control incentives when assessing MPS's role in prescription drug programs.

Community Pharmacy Services↗
PubMed1989

Evaluation of long-term triazolam use in an ambulatory Veterans Administration Medical Center population.

Triazolam is indicated for the short-term treatment of insomnia. To determine how it was being prescribed and used, we examined triazolam use in patients who had received the drug for greater than six weeks. We reviewed medical charts of 72 adult male patients from an ambulatory Veterans Administration population who had received a 30-day triazolam prescription with at least one refill. Results showed that although prescribed daily doses of triazolam were generally appropriate for the age of the patient being treated, the average length of therapy was 6.2 months. Seventy-five percent of the prescriptions had been written for a one-month supply with five refills. Neither prescriber specialty nor level of training was significantly related to length of therapy. Thirty-nine of the patients (54 percent) were available for a telephone interview to determine how the drug was actually being used and the adverse effects profile. Over 60 percent claimed to be taking the drug every night, 95 percent at the dose prescribed. Sixty-seven percent of the patients taking triazolam nightly reportedly did not sleep as well if they tried a night without the drug. Apart from effects on sleep, dizziness and confusion were the most commonly reported adverse effects. As a result of this study, automatic stop orders on discharge were implemented to limit triazolam therapy to inpatient stays. Physicians must evaluate the need for continued hypnotic therapy so that a longer-acting agent like flurazepam may be used if chronic medication is necessary.

Drug Prescriptions↗
PubMed1989

Investigational drug practices in Michigan hospitals.

All 188 acute-care hospitals in Michigan with licensed pharmacies were surveyed to assess compliance with recommendations of ASHP, FDA, and the Joint Commission on Accreditation of Healthcare Organizations related to investigational drug use; other practice issues related to investigational drugs but not covered in those guidelines were also studied. Pharmacy directors were questioned about their practices for approving, prescribing, procuring, storing, and labeling investigational drugs; preparation, content, and use of investigational drug data sheets; record keeping; personnel issues; and other investigational drug services provided by the pharmacy department. The response rate was 84.5% (159 completed questionnaires returned), but only 44 respondents (27.7%) indicated that investigational drugs were currently used in their institutions. Written investigational drug policies and procedures were available in 116 (73.0%) of the responding pharmacy departments. Respondents currently handling investigational drugs had high rates of adherence for the following practice guidelines: preparation of data sheets (75.0%), storage (97.7%), monitoring of investigational drug use and stock levels (79.5%), and maintaining perpetual inventories (79.5%). Areas with relatively poor adherence rates included pharmacy department preparation of investigational drug patient-information sheets (20.5%), maintaining information within the pharmacy on minimum stock levels (53.9%), mode of shipment (30.8%), time to receive investigational drugs after order placed (38.5%), acceptance of nursing transcriptions of oral orders (56.8%), including "investigational drug" on the dispensing label (55.8%), and approval of data sheets by the investigator and the institutional review board (40.5% and 37.8%, respectively). Pharmacy departments, regardless of hospital size, should improve their adherence to ASHP, FDA, and Joint Commission guidelines for handling investigational drugs.

Documentation↗
PubMed1987

Effect of innovation characteristics on pharmacists' use of written patient medication information.

There is increasing pressure on pharmacists to provide written medication information in patients. Unfortunately, recent evidence indicates that this practice has not yet been extensively adopted. Pharmacists' reluctance can be explained partially by Diffusion of Innovations Theory which states that the characteristics of an innovation (i.e. relative advantage, compatibility with needs, experience and values, complexity and trialability) can affect its rate of adoption within a community. This theory was tested in a group of Michigan community pharmacists who recently purchased medication information sheets developed by the Michigan Pharmacists Association. Results were compared with a randomly selected sample of similar pharmacists who had not yet purchased the kit. Study findings support the theory that the adoption of an innovation (i.e. use of written information) is affected by the adopters' perception of certain innovation characteristics. The most influential factor in the adoption of the written information sheets was the extent that they were compatible with the pharmacists' business needs, professional values, and past experiences with providing written information to patients. The most important deterrent to adoption of the sheets appeared to be the perceived complexity in implementation at the practice site.

Communication↗
PubMed1987

Costs associated with the inappropriate route of administration of parenteral histamine2-receptor antagonists.

The objectives were to assess the parenteral route for cimetidine and ranitidine and to determine excess medication costs associated with inappropriate use. Criteria were based on clinical situations that do not permit oral therapy, result in questionable dry absorption, or require a more rapid onset of action. The parenteral route was assessed as appropriate, inappropriate, or questionable. During two months, parenteral therapy was prescribed for 199 adult inpatients. Initially, 63 percent received the parenteral form appropriately; only 16 percent continued to receive the parenteral form appropriately throughout therapy. Less than half of the parenteral doses were determined to be appropriate. A major reason appears to be that orders are not changed as patients' conditions improve. Excess medication costs attributed to inappropriate parenteral therapy for the study period amounted to $6796 or $8002, depending on whether questionable doses were considered appropriate or inappropriate, respectively. An annual projected savings of $40,776 or $48,012 could be achieved if oral doses had been administered in place of inappropriate parenteral therapy.

Cimetidine↗
PubMed1987

Compliance measure development and assessment of theophylline therapy in ambulatory patients.

The objectives of this study were: (a) to develop a drug serum level-based compliance measure which incorporated pharmacokinetic analysis of patient and drug parameters and to compare it to refill records, an indirect measure, and (b) to use that measure to determine whether pharmacist consultation increased compliance. Sixty adult, male chronic obstructive pulmonary disease out-patients who received theophylline were randomly assigned to one of two groups with counselling provided to experimental-group patients only. Compliance was measured by the ratio of actual serum theophylline level to that predicted by pharmacokinetic estimation and by the number of refills in 155 days. More experimental-group patients had actual levels within both +/- 10% and +/- 20% of predicted levels (P = 0.0006 and 0.04). They also obtained more refills than control patients (P = 0.05). The pharmacokinetically based serum level measure appeared to be the more useful measure for identifying non-compliance, which suggests that it is of greater value than existing measures. In addition, the results suggest that comprehensive consultation by a clinical pharmacists can improve compliance with theophylline therapy in the out-patient setting.

Adult↗