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PubMed1994

Impact of regulation on benzodiazepine prescribing to a low income elderly population, New York State.

On 1 January 1989, in an effort to reduce diversion of benzodiazepines for illicit use and reduce inappropriate prescribing, a regulation was implemented requiring the reporting of all benzodiazepine prescriptions to the New York State Department of Health. To assess the impact of the regulation on prescribing practices to the elderly, we followed the number of benzodiazepines and other central nervous system medications prescribed to a cohort of participants in an elderly pharmaceutical insurance program. Benzodiazepines were prescribed for 4652 (22%) of the 20,944 patients studied. By the last quarter of 1989, benzodiazepines were prescribed for 3120 (15%) patients, a decrease of 33%. The number of prescriptions of benzodiazepines decreased by 5010 (45%), from 11,123 to 6113. Decreases in the number of prescriptions were similar across benzodiazepine brands (range 40-56%). Statistically significant (p < 0.05) decreases were seen in all sex, age, race and marital status groups. Increases in number (and percent increases) of prescriptions for miscellaneous anxiolytics (i.e. hydroxyzine (399, 69%), meprobamate (299, 149%), buspirone (263, 111%), chloral hydrate (138, 265%), antidepressants (658, 19%), barbiturates (150, 29%), and tranquilizers (198, 19%), some of which may be more toxic or less effective, were noted. New York State's reporting regulation was effective in reducing both the number of patients being prescribed benzodiazepines and the number of prescriptions given to those who remain on benzodiazepines in the elderly population studies.

Aged↗
PubMed2005

The drug utilization patterns of Hong Kong Chinese adults.

This paper reports the findings of a pilot study on the drug utilization patterns, including both Western and Chinese medications, of Hong Kong Chinese adults with an aim to plan quality community-based safe medication practice education. A tool for collecting the drug utilization patterns was developed for the purpose of the study. One hundred Chinese adults were invited to participate in this pilot study. Structured interviews were used in the study. Drug utilization patterns of the subjects in the preceding 2 weeks were investigated. It was found that 44 adults took Western medications such as cough and cold remedies or analgesics. Nineteen adults took Chinese medications such as tonics or prescriptions for relieving exterior syndrome. Adults who took Western medications understood the effects and side effects of the drugs better than those who took the Chinese medications although their knowledge was not sufficient to allow them to perform safe medication practice. It was concluded that the tool is useful in the future, in large-scale research studies to promote safe medication practice.

Adult↗
PubMed2005

A survey on the extent of medication storage and wastage in urban Iranian households.

BACKGROUND: Prescription and nonprescription medications constitute a substantial proportion of the health care costs of countries. National drug policies and attitudes toward medication use may play a role in irrational prescribing and consumption of medicines, leading to drug wastage. The limited resources of developing countries warrant more careful assessments of current national drug policies. OBJECTIVE: This study quantified the amounts and types of medications that are stored in a sample of urban Iranian households and estimated the extent of drug wastage in these families. METHODS: A literature search was conducted using MEDLINE and International Pharmaceutical Abstracts for 1966 to 2004 to identify articles on drug utilization and wastage. Randomly selected households in a large city in Iran were visited to determine the amounts and types of medicines stored in these households. A questionnaire was used to collect information about medication use in these families. RESULTS: A total of 512 households were assessed. The mean (SD) family size of household respondents was 4.3 (1.6) members. Mothers were responsible for managing medications in 58.1% (291/501) of families. Presence of chronic illness, insurance coverage, higher economic status, literacy among fathers, and siblings without medically related jobs were the variables that showed a significant relationship with the amount of medicines found in the households. The mean (SD) numbers of unit doses of medicines and of drug products found in these households were 238.5 (198.6) and 22.99 (20.1), respectively. The most common therapeutic classes of medications kept at home were central nervous system agents, anti-infectives, and gastrointestinal medications. The real and potential medication wastage was estimated to be 38.8% and 53.8%, respectively. CONCLUSIONS: Medications were stored in large quantities in these urban Iranian households, and a large percentage was being wasted. Drug-use assessments and a comprehensive evaluation of the current national drug policies are warranted to curtail this problem.

Adult↗
PubMed1995

OBRA '90: the impact on pharmacists and patients.

Two separate studies were conducted in Georgia for this investigation. The first study measured by observation, pharmacists' compliance with the mandates of the Omnibus Budget Reconciliation Act of 1990 (OBRA '90) before (December 1992) and after (June 1993) the law took effect in January 1993. The second assessed patient awareness, experience, and degree of cooperation with pharmacists in complying with OBRA '90. Eight chain and four independent pharmacies were recruited for the first study. For the second, a representative sampling of patients answered questions by telephone. Findings from the pharmacy study indicated more streamlined information gathering, more time devoted to prospective drug utilization review, and a 29% increase in counseling frequency in the post-OBRA '90 period. Some changes may be due to increased computer sophistication. The patient survey indicated a lower frequency of counseling than was reported in the pharmacy study. Patients appeared willing to supply information to pharmacists when patients viewed it as a way to improve the care they receive.

Georgia↗
PubMed2003

Public and private sector responses to essential drugs policies: a multilevel analysis of drug prescription and selling practices in Mali.

Many African countries have introduced cost recovery mechanisms based on the sale of drugs and measures aimed at improving drug supply. This study compares prescribing and selling practices in Mali, in 3 cities where the public sector contributes differentially to the supply of drugs on the market. Multilevel models are used to analyse the content and cost of 700 medication transactions observed in 14 private and public legal points of sale. Results show that the objective of improving access to drugs seems to have been achieved in the sites studied. Costs of prescriptions were lower where public health services had been revitalized. Affordable generic drugs were accessible and widely used, even in the private sector. However, measures intended to rationalize the prescription and delivery of drugs did not always have the desired effect. While agents in the public sector tended to prescribe fewer antibiotics, injectables, or brand-name drugs, the data confirm the virtual absence of advice concerning the use or the side effects of the drugs in both public and private sectors. In addition, data supported the notion that the public and private sectors are closely intertwined. Notably, availability of drugs in the public sector contributed to diminishing the prices charged in the private sector. Similarly, the use that agents in the public sector made of the opportunities afforded by the presence of the private pharmaceutical sector provided another illustration of interrelatedness. Finally, the data showed that the presence of a private sector, which has not been affected by measures aimed at rationalizing prescription and sales practices, limits the effects of measures implemented in the public sector. More assertive policies, based on strategies encompassing actors in the private sector, are needed to increase the safety and effectiveness of prescription and sales practices.

Community Health Centers↗
PubMed2006

[Evaluation of rational prescribing and dispensing of medicines in Mali].

Pharmaceutical policy in Mali is based on the concept of essential medicines and procurement of generic medicines. Unfortunately, increasing availability of generic medicines via different promotional programs can often be accompanied by their irrational use. This survey was thus designed to evaluate rational prescribing and dispensing of medicines in Mali. A cross-sectional survey was conducted from 1998 to 2005 in 30 primary health centers and 30 private dispensaries; in Bamako and in 6 of the 8 other regions of the country. In each of the visited facilities, 20 prescriptions dispensed at the time of the survey were collected. The average number of medicines per prescription was 3.2+/-1.3 and 2.8+/-1.2 respectively in the public and private sectors. Medicines were prescribed under generic name in 88.2% of the public sector prescriptions and in 30.9% of the private sector ones. Antibiotics were prescribed in 70.4% of the public sector prescriptions and in 50.0% of the private sector prescriptions. In the public sector 33.2% of the prescriptions had injections compared with 14.3% in the private sector (p<0.001). The median price per prescription was lower in the public sector (1575.0 CFA F, or 2.4 Euros, of which 91.3% were actually purchased by the patient) than in the private sector (5317.5 CFA F, or 8.1 Euros, of which 84.6% were purchased). Generic medicines are being used in the public sector but less frequently than in private practice. As therapeutic guidelines are already available, it would be useful to institute interactive information for practitioners through intensive visits by more experienced supervisors. The quality of the prescriptions could thus be optimized.

Cross-Sectional Studies↗
PubMed2003

The effect of incentive-based formularies on prescription-drug utilization and spending.

BACKGROUND: Many employers and health plans have adopted incentive-based formularies in an attempt to control prescription-drug costs. METHODS: We used claims data to compare the utilization of and spending on drugs in two employer-sponsored health plans that implemented changes in formulary administration with those in comparison groups of enrollees covered by the same insurers. One plan simultaneously switched from a one-tier to a three-tier formulary and increased all enrollee copayments for medications. The second switched from a two-tier to a three-tier formulary, changing only the copayments for tier-3 drugs. We examined the utilization of angiotensin-converting-enzyme (ACE) inhibitors, proton-pump inhibitors, and 3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitors (statins). RESULTS: Enrollees covered by the employer that implemented more dramatic changes experienced slower growth than the comparison group in the probability of the use of a drug and a major shift in spending from the plan to the enrollee. Among the enrollees who were initially taking tier-3 statins, more enrollees in the intervention group than in the comparison group switched to tier-1 or tier-2 medications (49 percent vs. 17 percent, P<0.001) or stopped taking statins entirely (21 percent vs. 11 percent, P=0.04). Patterns were similar for ACE inhibitors and proton-pump inhibitors. The enrollees covered by the employer that implemented more moderate changes were more likely than the comparison enrollees to switch to tier-1 or tier-2 medications but not to stop taking a given class of medications altogether. CONCLUSIONS: Different changes in formulary administration may have dramatically different effects on utilization and spending and may in some instances lead enrollees to discontinue therapy. The associated changes in copayments can substantially alter out-of-pocket spending by enrollees, the continuation of the use of medications, and possibly the quality of care.

Angiotensin-Converting Enzyme Inhibitors↗
PubMed2002

Prevalence and cost savings of therapeutic interchange among U.S. hospitals.

The prevalence and cost savings of therapeutic interchange (TI) among teaching, nonteaching, and investor-owned hospitals in the United States was studied. A survey was sent to all directors of pharmacy at hospitals listed in the 1999 American Hospital Association directory as having more than 100 beds; 463 (29.8%) hospitals responded. The survey elicited data about hospital demographics, the policies and personnel involved in TI, and the estimated cost savings incurred by the use of TI. Eighty-eight percent of teaching, 89% of nonteaching, and 100% of investor-owned hospitals reported having established TI policies and procedures; 88% of responding hospitals reported the use of TI as a means of formulary management. Individuals involved in the decision-making process for TI policies included physicians, pharmacists, and pharmacy and therapeutics committee members. Most responding hospitals reported having an automatic interchange procedure, and few required physician consent before the substitution was made. The most commonly substituted medication classes were histamine H2-receptor antagonists, proton-pump inhibitors, antacids, and quinolones. Differences in TI procedures and the medication classes commonly substituted were not significant between teaching and nonteaching hospitals. The annual dollar savings was estimated by 36% of teaching, 38% of nonteaching, and 50% of investor-owned hospitals and determined by record keeping in 18% of teaching, 20% of nonteaching, and 40% of investor-owned hospitals. Eighty-eight percent of teaching, 89% of nonteaching, and 100% of investor-owned hospitals have established TI policies. Significant variation in cost savings occurred when hospitals attempted to estimate the annual dollar savings, as no adequate commercially available software exists to perform this task.

Cost Savings↗
PubMed2002

Survey of hospital policies regarding low-molecular-weight heparins.

Hospital policies regarding the use of low-molecular-weight heparins (LMWHs) were studied. A questionnaire addressing the formulary status of LMWH products, the use of prescribing guidelines, programs for therapeutic interchange, and policies to promote alternatives to LMWHs when appropriate was prepared. The questionnaire was mailed in January 2001 to pharmacy directors at 70 hospitals located in 19 states. All the hospitals were members of a national group purchasing organization. Forty-nine usable responses were received, for a response rate of 70%. Enoxaparin and dalteparin were the LMWH products most likely to be on the respondents' formularies (98% and 29% of hospitals, respectively). About 29% of the hospitals reported having guidelines on the use of LMWHs. Among hospitals that did not, most indicated that they were considering or would like to implement such guidelines. The most commonly cited barrier to the development and implementation of guidelines was lack of pharmacy personnel. Ten percent of the respondents reported having therapeutic-interchange programs for LMWHs. Cited barriers to therapeutic interchange programs included lack of therapeutic equivalence among products and lack of comparable labeled indications. Policies to promote alternatives to LMWHs were reported by 18% of the respondents. A multihospital survey showed that many hospitals wanted but relatively few had prescribing guidelines for LMWHs.

Dalteparin↗
PubMed2002

Prescription habits of dispensing and non-dispensing doctors in Zimbabwe.

The number of dispensing doctors has increased in the last decade, but the implication of this trend on the quality of health care and drug use is unknown. We present a comparative drug utilization study of 29 dispensing doctors and 28 non-dispensing doctors in Zimbabwe based on standard indicators developed by the World Health Organization. Dispensing doctors prescribed significantly more drugs per patient than non-dispensing doctors (2.3 versus 1.7), injected more patients (28.4% versus 9.5%), and prescribed more antibiotics (0.72 versus 0.54) and mixtures (0.43 versus 0.25) per encounter. Dispensing doctors also spent significantly less time on each encounter (8.7 min versus 13.0 min) than their non-dispensing colleagues. The use of generic name, brand name and essential drugs did not differ significantly between the two groups of practitioners. Multivariate analyses controlling for gender, race, place of education, location of practice and patients seen per day showed that dispensing by doctors was associated with less clinically and economically appropriate prescribing. These findings suggest that the quality of health care--as related to drug use, patient safety and treatment cost--is lower with dispensing doctors than with non-dispensing doctors.

Cohort Studies↗
PubMed2003

Economic consequences of underuse of generic drugs: evidence from Medicaid and implications for prescription drug benefit plans.

OBJECTIVE: To calculate the financial impact of underuse of generic medications in state Medicaid programs. DATA SOURCES/STUDY SETTING: State-by-state data on Medicaid drug spending for 48 states and the District of Columbia in calendar year 2000. STUDY DESIGN: We compared the total amount paid by each state Medicaid program for brand name prescriptions with the amount that would have been paid for generic versions of the same agent, to estimate the level of unrealized savings from use of substitutable generic drugs. We also examined whether variation in prices between states represented a potential source of unrealized savings. PRINCIPAL FINDINGS: Analysis of state-by-state Medicaid prescription drug spending in 2000 identified potential savings of $229 million that could have been realized from greater use of generic drugs. If the best available prices from each state had been used nationally, savings would have increased to $450 million. The majority of the unrealized savings were concentrated in a small group of medications, including clozapine, alprazolam, and levothyroxine. CONCLUSIONS: Federal regulations on prescription drug reimbursement limit the excess spending on brand name drugs in the Medicaid program to a small percentage of total spending, although the absolute dollar amount is large. Further savings could be realized if lowest available prices were used nationwide. Concentrating on specific agents may be a productive way to address the unrealized savings.

Centers for Medicare and Medicaid Services, U.S.↗
PubMed1994

The compatibility of the retail setting with a patient-based practice model: reports from community pharmacists.

The patient counselling and prospective drug utilization review mandates of the Omnibus Budget Reconciliation Act of 1990 raise the question of how compatible the retail pharmacy setting in the United States is with a patient-based model of pharmacy practice. In order to investigate this question, a self-administered questionnaire was distributed by pharmacy students to a convenience sample of pharmacists with at least one year's experience in the community setting. The questionnaire asks respondents to recall two incidents: one that caused them to gain or retain a patient or that was for some reason a source of professional satisfaction, and one that may have caused the loss of a patient or that they would handle differently if faced with the situation or problem again. The respondents practice in pharmacies in and around a large midwestern city. Data analysis showed that respondents tend to identify patient-based activities when recalling appropriate behaviours and traditional or customer-based activities when recalling inappropriate behaviours or mistakes. Patient-based activities can sometimes result in the loss of business, but they can also result in patronage gains, especially when performed in conjunction with good customer service. In summary, these pharmacists do implement a patient-based model in some situations. The patient-based and customer-based models can be complementary in that the patient can benefit from the services of an expert health professional while simultaneously being treated with the respect and 'customer knows best' attitudes indicative of the retail setting.

Attitude of Health Personnel↗
PubMed2004

Spironolactone use in patients with heart failure.

BACKGROUND: The addition of spironolactone, an aldosterone antagonist, to standard therapy can reduce the risk of both morbidity and mortality in patients with severe heart failure. OBJECTIVE: To evaluate the use of spironolactone in class III and IV heart failure patients in four urban teaching hospitals. METHODS: We conducted a concurrent medical record review of 163 patients with documented heart failure admitted to a general medicine service over a 5-week period. Data retrieved included patient demographics, heart failure class, left ventricular ejection fraction, spironolactone contraindications, spironolactone use, dose and frequency, and other heart failure medication use, dose and frequency. All data reflected patients' baseline status. RESULTS: Our patient population was 80% white people, 61% male, with a mean age of 70 years (35-99). A total of 114 had class III or IV heart failure (70%). Angiotensin-converting enzyme inhibitors or appropriate alternative were prescribed in 117 (72%) patients, whereas beta-blockers were used in 121 (74%) patients. Fifty-seven patients met spironolactone ideal candidate criteria. Of these, eight (14%) were appropriately prescribed spironolactone. CONCLUSIONS: Three years after publication of the Randomized Aldactone Evaluation Study, spironolactone is underutilized in the treatment of heart failure. Results of this study indicated that the majority of patients in class III or IV heart failure were not prescribed spironolactone. Improvements in spironolactone prescribing are needed.

Adult↗
PubMed1993

Effect of fundholding and indicative prescribing schemes on general practitioners' prescribing costs.

OBJECTIVE: To compare general practitioners' prescribing costs in fundholding and non-fundholding practices before and after implementation of the NHS reforms in April 1991. DESIGN: Analysis of prescribing and cost information (PACT data; levels 2 and 3) over two six month periods in 1991 and 1992. SETTING: Oxford region. PARTICIPANTS: Three dispensing fundholding practices; five non-dispensing fundholding practices; and seven non-dispensing, non-fundholding practices. MAIN OUTCOME MEASURES: Percentage change in net cost of ingredients, number of items prescribed, average cost per item, and proportion of generic drugs prescribed after NHS reforms. RESULTS: Prescribing costs increased in all practices in the six months after the reforms. The net costs of ingredients increased among dispensing fundholders by 10.2%, among non-dispensing fundholders by 13.2%, and among non-fundholders by 18.7%. The number of items prescribed also increased in all three groups (by 5.2%, 7.5%, and 6.1% respectively). The increase in average cost per item was 4.8% for dispensing fundholders, 5.3% for non-dispensing fundholders, and 11.9% for non-fundholders. Dispensing fundholders increased the proportion of generic drugs prescribed from 26.9% to 34.5% and non-dispensing fundholders from 44.5% to 48.7%; non-fundholders showed no change (47%). Five of the eight fundholding practices made savings in their drugs budgets at the end of the first year of fundholding (range 2.9-10.7%; the three other practices overspent by up to 3.6%). All non-fundholding practices exceeded their indicative prescribing amounts (range 3.2-20.0%). CONCLUSIONS: Fundholding has helped to curb increases in prescribing costs, even among dispensing general practitioners, for whom the incentives are different. Indicative prescribing amounts for non-fundholding practices do not seem to have had the same effect.

Drug Costs↗