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Jerry Avorn

Publications and source records attributed to Jerry Avorn.

At least 55 records · Page 3Linked to original sources
PubMed2005

University-based science and biotechnology products: defining the boundaries of intellectual property.

The pharmaceutical and biotechnology industries have long relied on patenting as the primary means of allocating ownership and control over new discoveries. Yet, patent protection is a double-edged sword that has major implications for the future of innovation in biomedical science in the United States. Excessive "upstream" patenting of genes and molecular targets could hinder further research by creating a need for expensive and inefficient cross-licensing. However, limiting such basic science patenting could allow private entities to use the results of years of costly publicly funded research to produce and market lucrative products without compensating university- or public sector-based innovators. Academic and other nonprofit research centers would, therefore, be deprived of revenue for pursuing novel therapeutics or other seminal research work that may not be patentable. Recent court cases illustrate the inherent conflicts in allocating ownership and control of basic biomedical discoveries. Several options exist to avoid the complex problems of overlapping basic science patents while still rewarding pivotal discoveries and encouraging further innovation. These include establishing basic science patent pools and mandating arbitration arrangements that would assign credit and royalties for biotechnology innovations that depend on prior research that was performed, financed, or both in the public sector.

Academic Medical Centers↗
PubMed2005

Development and assessment of indicators of rheumatoid arthritis severity: results of a Delphi panel.

OBJECTIVE: To develop a set of indicators for assessing the severity of rheumatoid arthritis (RA) through medical records. METHODS: A list of 47 potential indicators of RA was reviewed by an expert Delphi panel of 6 rheumatologists. The Delphi method is a formal approach for gathering expert opinion. The 47 potential indicators included items from the following 5 categories: radiologic and laboratory findings, clinical and functional status measures, extraarticular manifestations, prior surgical history, and medications. The panelists rated the potential indicators' relationship to RA disease severity. Each panelist rated each indicator on a scale of 0-6, in which 0 indicated no relationship at all with severe RA and 6 indicated a perfect relationship with severe RA. After a baseline set of ratings, a literature review was distributed to the panelists along with the panel's initial mean ratings and the ranges. The panelists then met to discuss the literature and rerate all indicators. RESULTS: After repeat ratings and review of relevant literature, the panel rated 28 of 47 (60%) potential indicators as having a strong or very strong relationship to severe RA. These 28 indicators were drawn from all 5 categories of potential indicators. There was agreement among the panelists on ratings for 41 of 47 indicators. Agreement was defined as a range of scores among the panelists </=3. CONCLUSION: A Delphi panel of rheumatologists agreed that data generally available in medical records may serve as potential indicators of severe RA.

Antirheumatic Agents↗
PubMed2005

Osteoporosis action: design of the healthy bones project trial.

Although osteoporosis is common in older adults, it is often under-diagnosed and under-treated. We developed community-based patient- and physician-directed interventions for fracture prevention and compared them in a 2 x 2 factorial randomized controlled trial. The study population included older adults who were enrolled in a state-run pharmacy benefits program (The Pharmaceutical Assistance Contract for the Elderly in Pennsylvania) for Medicare beneficiaries. We randomly assigned 826 primary care physicians and their 31,715 patients to one of four trial arms--no patient and no physician intervention, patient but no physician intervention, physician but no patient intervention, both patient and physician interventions. The patient intervention consisted of targeted communication about fall and fracture prevention and osteoporosis diagnosis and treatment. It was delivered through several mailings. The physician intervention entailed one-on-one academic detailing encounters covering the same topics. The composite primary endpoint consisted of use of osteoporosis medication or a bone mineral density test. Other endpoints included patient's knowledge and attitudes towards fractures and osteoporosis, use of lower extremity strengthening to prevent falls, and the occurrence of fractures. All outcomes will be analyzed using random effects models accounting for clustering of subjects within physicians' practices.

Aged↗
PubMed2005

Sudden uncontrollable somnolence and medication use in Parkinson disease.

BACKGROUND: Episodes of sudden uncontrollable somnolence have been reported in patients with Parkinson disease (PD) receiving dopamine agonists, including pramipexole and ropinirole, but controversy persists concerning their nature, severity, and frequency. OBJECTIVES: To quantify the risk of sudden uncontrollable somnolence in patients taking specific PD medications and to define its predictors. METHODS: We contacted 929 patients with PD and administered a 45- to 60-minute interview addressing medication use, adverse events, and the patient's clinical status in the preceding 6 months. Their physicians completed record reviews detailing their clinical histories and drug regimens. The outcome of interest in this case-control study was an episode of somnolence that was uncontrollable, severe, and inappropriate, such as while driving or engaged in social activity. For multiple events, the first was chosen as the index event. For each case, we sampled control time from all respondents who had no event as of the index time for that case. Multiple logistic regression was used to adjust for potential confounders. RESULTS: Episodes of uncontrollable somnolence were reported by 22% of all respondents. After controlling for age, sex, PD duration and severity, frailty, and other medication use, we found that patients receiving a dopamine agonist (pramipexole, ropinirole, or pergolide) were nearly 3-fold as likely to have episodes of sudden uncontrollable somnolence (odds ratio, 2.8; 95% confidence interval, 1.8-4.2) compared with all other PD medication users. Similar risks were seen for the 3 agents, pramipexole, ropinirole, and pergolide, each compared with levodopa alone (odds ratio, 2.2, 1.8, and 2.1, respectively), with a clear dose-response relationship for each. No increase in risk was seen with any other drugs studied. CONCLUSIONS: Dopamine agonists widely used for the management of PD significantly increase the risk of sudden uncontrollable somnolence in a dose-related manner. Greater attention to this potentially serious adverse effect will be necessary to improve the safety of use of this important category of PD drugs.

Adult↗
PubMed2005

Statin lipid-lowering drugs and bone mineral density.

BACKGROUND: HMG Co-A reductase inhibitors (statin lipid-lowering drugs) have been associated with a reduced rate of fractures in some studies, but not in others. We examined the relationship between statin use and bone density among postmenopausal women. METHODS: We conducted a cross-sectional survey at one academic medical center. Postmenopausal women who underwent bone densitometry and agreed to a telephone interview were surveyed about osteoporosis risk factors, use of hormone replacement therapy and osteoporosis medications and statin exposure. We then developed linear regression models adjusting for known counfounders to assess the relationship between statin use and bone mineral density (BMD). RESULTS: Of 339 women studied, 162 were current or past users of statins, and 177 were not. Statin users and non-users were similar with respect to age, race, prior fracture history, the presence of medical conditions associated with osteoporosis, use of medications for osteoporosis, use of tobacco and use of oral glucocorticoids. Statin users had significantly higher body mass index (BMI) and rates of thiazide use, and were more likely to abstain from alcohol. After adjusting for important confounders, we found that statin use was associated with a significantly higher t-score at the total hip (-0.53 +/- 0.17) compared with non-users (-0.83 +/- 0.18; p = 0.02). At the lumbar spine, there was a trend toward higher t-scores in statin users (-0.91 +/- 0.24) compared with non-users (-1.21 +/- 0.23; p = 0.08). CONCLUSIONS: These results support the hypothesis that statin use is associated with higher BMD. While it is unclear whether their relationship is causal, further controlled studies examining bone formation and resorption would help determine the clinical implications of these findings.

Bone Density↗
PubMed2005

Lipid levels and bone mineral density.

PURPOSE: There has been considerable debate about the potential relationship between the use of statin lipid-lowering drugs and fracture risk; several observational studies suggest a protective effect but no randomized controlled trials have confirmed such a benefit. Because statins are given preferentially to persons with hyperlipidemia, if lipid levels were associated with bone mineral density, this could explain the discrepancy between epidemiological observations and randomized controlled trials. The aim of this study was to examine the relationship between lipid levels and bone mineral density. SUBJECTS AND METHODS: We included the 13592 participants in the National Health and Nutritional Examination Survey (NHANES) III who had bone mineral density and lipid levels measured; participants who reported the use of a lipid-lowering therapy were excluded. We examined the unadjusted bone mineral density across quintiles of total cholesterol, low-density lipoprotein (LDL), and high-density lipoprotein (HDL). We then constructed multivariable models, including age, sex, body mass index, and other potential confounders. RESULTS: In crude analyses, higher total cholesterol and LDL levels were associated with lower bone mineral densities (both P values for trend <.001), whereas higher HDL levels were associated with higher bone mineral densities (P value for trend <.001). However, in fully adjusted models, there was no significant relationship between total cholesterol, LDL, or HDL levels and bone mineral density (all P values for trend >.1). CONCLUSIONS: These results do not support a relationship between lipid levels and bone mineral density.

Adolescent↗
PubMed2005

A Medicare database review found that physician preferences increasingly outweighed patient characteristics as determinants of first-time prescriptions for COX-2 inhibitors.

OBJECTIVE: Although innovative drugs may be underprescribed by some physicians, it is possible that rapid adoption after market introduction may lead to prescribing such drugs to patients without a clear indication. We sought to quantify the relative contributions of patient vs. physician factors to the decision to prescribe selective cyclooxygenase-2 (COX-2) inhibitors during the first 2 years of their availability. METHODS: A cohort of 37,957 Medicare beneficiaries who were enrolled in the Pharmaceutical Assistance Contract for the Elderly in Pennsylvania was identified. All patients had started using nonselective nonsteroidal anti-inflammatory drugs (NSAIDs) or selective COX-2 inhibitors between January 1, 1999, and December 31, 2000, and had no prior NSAID use. All had full prescription drug coverage, including NSAIDs and selective COX-2 inhibitors. Subsequent prescriptions were not considered. We quantified the amount of variation in first-time COX-2 prescribing that could be explained by predictors of gastrointestinal (GI) toxicity, other patient characteristics, or physician preferences. Explained variation was calculated as the R(2) (standardized to range from 0 to 1) from unconditional logistic regression and random intercept mixed effects logistic regression, fitted separately in each of eight consecutive 3-month periods. RESULTS: COX-2 inhibitors were adopted as the preferred NSAID by 55% of physicians within 180 days after they were marketed. In new NSAID users, COX-2 prescribing was twice as dependent on physician prescribing preferences (R(2)=60%) as on the combined predictors of GI toxicity (R(2)=3%) and other patient factors (R(2)=30%). The ratio of COX-2 prescribing explained by physician preferences over the contribution of patient factors increased from 2 to more than 10 over a 24-month period. CONCLUSIONS: First-time COX-2 inhibitor prescribing was somewhat dependent on patient factors in the first quarter of marketing, but the proportional influence of physician preferences increased substantially over the following 2 years, raising the question of why physician factors and not patient risk factors influence COX-2 inhibitor prescribing.

Aged↗
PubMed2005

A review of uses of health care utilization databases for epidemiologic research on therapeutics.

OBJECTIVE: Large health care utilization databases are frequently used in variety of settings to study the use and outcomes of therapeutics. Their size allows the study of infrequent events, their representativeness of routine clinical care makes it possible to study real-world effectiveness and utilization patterns, and their availability at relatively low cost without long delays makes them accessible to many researchers. However, concerns about database studies include data validity, lack of detailed clinical information, and a limited ability to control confounding. STUDY DESIGN AND SETTING: We consider the strengths, limitations, and appropriate applications of health care utilization databases in epidemiology and health services research, with particular reference to the study of medications. CONCLUSION: Progress has been made on many methodologic issues related to the use of health care utilization databases in recent years, but important areas persist and merit scrutiny.

Bias↗
PubMed2005

Identification of individuals with CKD from Medicare claims data: a validation study.

BACKGROUND: Medicare claims data might provide an efficient source for outcomes research in patients with chronic kidney disease (CKD). However, in the absence of laboratory data, one would need to identify patients with CKD from diagnosis codes associated with health care claims. The validity of this approach to identify patients with CKD has not been sufficiently studied. METHODS: From chart abstraction, we obtained the first serum creatinine measurement of 1,852 elderly Medicare beneficiaries upon hospitalization for myocardial infarction and estimated each patient's glomerular filtration rate. We then searched all Medicare claims of the preceding year for the presence of a diagnosis code for diabetic nephropathy, hypertensive nephropathy, chronic renal insufficiency, acute renal failure, and miscellaneous other renal diseases. Using the gold standard of an estimated glomerular filtration rate less than 60 mL/min/1.73 m2 (<1.00 mL/s/1.73 m2) for definition of CKD, we calculated the sensitivity, specificity, and positive and negative predictive values for each of these diagnoses and combinations of these diagnoses. RESULTS: The sensitivity of individual diagnosis algorithms ranged from 2.7% for diabetic nephropathy to 17.5% for miscellaneous. However, miscellaneous had a lower specificity (95.5%) than all other individual diagnosis algorithms (all > or =99%). Using combinations of these algorithms improved sensitivity up to 26.6%, but at the cost of lower specificity. Positive predictive values generally were high (85.7% to 97.5%), but negative predictive values were low (32.4% to 37.4%). CONCLUSION: High positive predictive values indicate that Medicare claims data can be used to accurately identify patients with CKD for study. However, the utility of such databases for comparison of patients with CKD versus lesser degrees of CKD is limited.

Aged↗
PubMed2005

Underuse of ACE inhibitors and angiotensin II receptor blockers in elderly patients with diabetes.

BACKGROUND: National guidelines recommend angiotensin-converting enzyme (ACE)-inhibitor or angiotensin receptor blocker (ARB) therapy in patients with diabetes who also have hypertension and/or proteinuria to retard the progression of renal damage. However, little is known about the adequacy of adherence to these guidelines in elderly patients with diabetes and predictors of such appropriate ACE-inhibitor or ARB use. METHODS: Using linked medical claims from Medicare and the Pennsylvania Pharmaceutical Assistance Contract for the Elderly program, we studied a cohort of patients older than 65 years with diabetes. Baseline variables ascertained included age, sex, race, income, and several specific comorbid conditions. The outcome measure was at least 1 filled prescription for any ACE inhibitor or ARB during the quarter after the baseline year. We used multivariate logistic regression to measure predictors of use of the agents studied. RESULTS: Of 30,750 patients with diabetes studied, 21,138 patients (68.7%) also had hypertension and/or proteinuria. Of these, only 50.7% (95% confidence interval, 50.0 to 51.4) were administered an ACE inhibitor or ARB in the quarter studied. In multivariate analyses, failure to be administered either agent was associated significantly with older age, male sex, chronic lung disease, depression, dementia, and other mental illness. Greater rates of ACE-inhibitor or ARB use were found in patients with coronary artery disease or congestive heart failure. CONCLUSION: Only half the elderly patients with diabetes studied received recommended treatment with ACE inhibitors or ARBs. This shortfall could provide an opportunity for quality-improvement interventions that could result in important benefits in clinical outcomes for these high-risk patients.

Aged↗
PubMed2005

Adjusting for unmeasured confounders in pharmacoepidemiologic claims data using external information: the example of COX2 inhibitors and myocardial infarction.

BACKGROUND: Large health care utilization datasets are frequently used to analyze the incidence of rare adverse events from medications. However, possible confounders are typically not measured in such datasets. We show how to assess the impact of confounding by factors not measured in Medicare claims data in a study of the association between selective COX2 inhibitors and acute myocardial infarction (MI). METHODS: Using the Medicare Current Beneficiary Survey, we assessed the association between use of selective COX2 inhibitors and 5 potential confounders not measured in Medicare claims data: body-mass index, aspirin use, smoking, income, and educational attainment. For 8,785 participants > or =65 years, we estimated the prevalence of selective COX2 inhibitor use and also of each confounder, as well as the association between drug exposure and confounders. Estimates of the confounder-disease associations from the medical literature were used to calculate the extent of residual confounding bias for each potential confounder. RESULTS: Selective COX2 inhibitor users were less likely to be smokers (8% versus 10%) than nonselective NSAID users, while the prevalence of obesity was comparable (24%). Aspirin use was also balanced among all drug exposure categories. Failure to adjust for 5 potential confounders led to a small underestimation of the association between selective COX2 inhibitors and MI; comparing selective COX2 inhibitors with NSAIDs, the net bias was estimated to be -1.0% of the unknown true effect size (maximum range: -6% to 0%). CONCLUSIONS: In this example of the relationship between selective COX2 inhibitors and MI, not adjusting for 5 potential confounders in Medicare claims data analyses tended to slightly underestimate the association, but is unlikely to cause important bias.

Aged↗
PubMed2005

Suboptimal antidepressant use in the elderly.

Ongoing changes in available agents and health care delivery systems have made it imperative to study the quality of antidepressant use in vulnerable and traditionally underserved elderly. We conducted a retrospective cohort study among 12,130 new antidepressant users aged > or =65 years with a recent diagnosis of depression in the Pennsylvania Pharmaceutical Assistance Contract for the Elderly Program from January 1, 1994, to December 31, 1999. Additional use information was available through Medicare data. Potentially hazardous antidepressant regimens were defined as use of highly anticholinergic agents or daily dosages in excess of geriatric prescribing guidelines. Low-intensity regimens were defined by lower than recommended daily dosages, too-short durations of therapy, or lack of follow-up. Of all elderly antidepressant users, 43.3% were taking suboptimal regimens. Potentially hazardous regimens were used by 11.9%, including 7.3% taking highly anticholinergic agents and 5.3% using excessively high daily dosages. Low-intensity regimens were used by 34.8% of patients, including 7.6% with excessively low daily dosages, 19.3% with short durations of therapy, and 14.8% with inadequate follow-up. Potentially hazardous regimens were associated with ages 65 to 74 years, nursing home residence, cancer diagnoses, less comorbidity, use of other psychiatric medications, making more physician visits, and earlier calendar years. Low-intensity regimens were associated with ages > or =85 years, nonwhite race, greater comorbidity, fewer physician visits or inpatient days in the baseline 6 months, and not using other psychiatric medications. Suboptimal antidepressant use remains common in the elderly, especially the use of inadequately intensive regimens. Interventions are needed to improve the quality and outcomes of antidepressant use in this vulnerable population.

Aged↗
PubMed2005

Pharmacogenetic testing in the clinical management of schizophrenia: a decision-analytic model.

Clinical application of pharmacogenetic testing has been proposed as a means of improving treatment outcomes in psychiatry. The identification of a putative genetic test for better clozapine response in schizophrenia offers an opportunity to evaluate the cost-effectiveness of such testing. The authors performed a cost-effectiveness analysis of a genetic test that may identify individuals with greater likelihood of responding to clozapine treatment. We modeled a target population of schizophrenia patients in an acute psychotic episode, using a lifetime time horizon and societal perspective. Outcome measures included life expectancy, quality-adjusted life expectancy, costs, and incremental cost-effectiveness. Effects of variations in testing parameters were also examined. For a 30-year-old with schizophrenia, applying the pharmacogenetic test and treating those predicted to respond to clozapine with clozapine-first cost US $47,705 per additional quality-adjusted life-year, compared with treating all patients with conventional agents and reserving clozapine for treatment-resistant patients. In 1-way sensitivity analyses, test sensitivity and cost had the greatest impact on the incremental cost-effectiveness. We conclude that pharmacogenetic tests may achieve utility in clinical psychiatry, although their cost-effectiveness depends on several clinical parameters. More consistent reporting of test parameters such as sensitivity and specificity would greatly facilitate assessment of future pharmacogenetic studies.

Antipsychotic Agents↗
PubMed2005

Medication use patterns for osteoporosis: an assessment of guidelines, treatment rates, and quality improvement interventions.

OBJECTIVE: To assess current osteoporosis treatment guidelines, studies of osteoporosis treatment, and interventions to improve osteoporosis treatment. METHODS: We searched the medical literature for articles published between January 1, 1992, and December 31, 2003, and assessed all relevant articles using a structured data abstraction process. Because of substantial heterogeneity in study design, no attempt was made to summarize the data using meta-analytic techniques. RESULTS: Seventy-six articles met criteria for inclusion. Eighteen practice guidelines were studied. Most guidelines were consistent in key treatment recommendations. Among 18 studies of treatment rates in patients who had fractures, the weighted average varied from 22% for nonhormonal treatment to 19% for calcium. We found slightly higher treatment rates for patients taking oral glucocorticoids or for those older than 65 years. There were no consistent correlates of which patients received treatment. Six studies that examined treatment frequencies after bone densitometry all found that patients with lower bone mineral density were more likely to receive treatment. Most of the 8 interventions designed to improve osteoporosis treatment showed improvement in treatment rates; however, only 3 were randomized, and these showed the smallest effects. CONCLUSIONS: Frequency of treatment of osteoporosis in at-risk populations is low. However, our assessment of the literature revealed no clear and consistent predictors of undertreatment. Few carefully controlled interventions have been reported.

Adult↗
PubMed2005

Older adults' knowledge and beliefs about osteoporosis: results of semistructured interviews used for the development of educational materials.

OBJECTIVE: Although osteoporosis and associated fractures have been recognized as a significant public health problem, underdiagnosis and undertreatment are common. We investigated older adults' knowledge and beliefs regarding osteoporosis and its prevention, in order to develop effective osteoporosis health education messages and materials. These messages will be used as part of a trial that will test the efficacy of both public and doctor education to improve osteoporosis management. METHODS: We conducted semistructured one-on-one interviews with 15 older adult volunteers. A standard interview guide was developed and used for all interviews, which were audiotaped and transcribed. Key themes were extrapolated by 3 study staff using data abstraction forms. The data forms were then compared for consistency. RESULTS: We found that the term "osteoporosis" was well recognized, but many participants had only a fragmented understanding of its meaning. All participants identified osteoporosis as a serious condition, but many did not perceive themselves to be at personal risk for developing the condition. Many participants were confused about the difference between osteoporosis and osteoarthritis. Participants expressed reservations about taking prescription medications because of concerns over cost, side effects, and interactions with their current medications. CONCLUSION: Osteoporosis awareness is high, but the older adults interviewed had an incomplete understanding of the condition. This could hinder efforts to improve prevention and treatment of osteoporosis.

Aged↗
PubMed2004

Comparing the costs, risks, and benefits of competing strategies for the primary prevention of venous thromboembolism.

Systematic cost-effectiveness analyses of regimens used for preventing venous thromboembolism (VTE) are becoming increasingly important for several reasons: the aging of the population, with an accompanying increase in admissions for orthopedic procedures or other surgery; expanded indications for thromboprophylaxis in nonsurgical patients; and the introduction of more expensive new agents that may increase safety and efficacy. At the same time, health care systems are under unprecedented pressure to contain the costs of care, particularly medications. Such economic analyses are made more difficult by the paucity of clinical trials comparing treatment regimens to one another rather than to placebo. Several methodological issues must be kept in mind when evaluating cost-effectiveness analyses of VTE prophylaxis. These include the perspective from which the analysis is performed (eg, the health care system as a whole versus a particular payer), limitations of trial data (eg, artificially short time horizons), and definition of outcomes (eg, flawed definition and grouping together of adverse effects or treatment failures). Quantifying costs across nations and health care systems is problematic as well. Another challenge is the extrapolation of efficacy data from highly monitored study patients to routine practice settings. Nevertheless, cost-effectiveness analyses of VTE treatments conducted in orthopedic surgery, trauma, general surgery, and acute medical settings can help define the relationships among expenditures, adverse outcomes, and patient benefit for particular therapeutic strategies in a variety of clinical situations.

Cost-Benefit Analysis↗
PubMed2004

Medicaid prior-authorization programs and the use of cyclooxygenase-2 inhibitors.

BACKGROUND: Over the past five years, selective cyclooxygenase-2 inhibitors (coxibs) have accounted for a growing proportion of prescriptions for nonsteroidal antiinflammatory drugs (NSAIDs). To control these expenses, many state Medicaid programs have implemented prior-authorization requirements before coxibs can be prescribed. We evaluated the effect of such programs on the use of coxibs by Medicaid beneficiaries. METHODS: We surveyed state Medicaid agencies to determine whether prescription of coxibs required prior authorization and, if so, the criteria for authorization. For each program, we compared these criteria with evidence-based recommendations for prescribing of coxibs. Using data for all filled prescriptions in 50 state Medicaid programs from 1999 through the end of 2003, we calculated the proportion of defined daily doses of NSAIDs accounted for by coxibs. Time-series analyses were used to measure the changes in prescription patterns after the implementation of each prior-authorization program. RESULTS: By 2001, coxibs accounted for half of all NSAID doses covered by Medicaid. This proportion varied widely according to the state in 2003, from a low of 11 percent to a high of 70 percent of all NSAID doses. Twenty-two states implemented prior-authorization programs for coxibs during the study period. Overall, the implementation of such programs reduced the proportion of NSAID doses made up by coxibs by 15.0 percent (95 percent confidence interval, 10.9 to 19.2 percent), corresponding to a decrease of 10.28 dollars (95 percent confidence interval, 7.56 dollars to 13.00 dollars) in spending per NSAID prescription. The effect of such programs was not influenced by the degree to which a prior-authorization program incorporated evidence-based prescribing recommendations. CONCLUSIONS: The use of coxibs and spending on NSAIDs varies widely by state and declined substantially after the implementation of prior-authorization programs. Determining whether these reductions are clinically appropriate will have important implications for the development of rational drug-reimbursement policies.

Anti-Inflammatory Agents, Non-Steroidal↗