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PubMed1995

Appropriate prescribing in asthma and its related cost in east London.

OBJECTIVES: To determine the patterns of preventive to reactive prescribing for asthma among general practices in the City and East London Family Health Services Authority area and their relation to prescribing cost. DESIGN: Descriptive study of asthma prescribing during April 1992 to March 1993. Prescribing data were linked with general practice and population data on one database. SETTING: City and East London Family Health Services Authority area, including all general practices in contract with the authority, which covers the inner city London Boroughs of Hackney, Tower Hamlets, and Newham and the Corporation of the City of London. SUBJECTS: All 163 general practices as at 1 June 1993. MAIN OUTCOME MEASURES: Ratios of prescribed inhaled corticosteroids plus cromoglycates (prophylactic treatment) to bronchodilators; distribution of the cost of asthma prescribing; distribution of overall generic prescribing; proportion of asthma generic prescribing; distribution of cost of overall drugs prescribed per prescribing unit. RESULTS: Practices approved for band 3 health promotion or asthma surveillance and those with a general practitioner trainer had on average higher ratios of prophylactic to bronchodilator treatment and significantly higher asthma drug costs than other practices. Those practices with high levels of overall generic prescribing had significantly higher prophylactic to bronchodilator ratios than those with lower levels of generic prescribing. Practices with higher levels of asthma drug generic prescribing also had significantly higher prophylactic prescribing. However, the proportion of generically prescribed asthma drugs was lower than overall generic prescribing. There was no correlation between the ratio of prophylactic to bronchodilator asthma prescribing and the proportion of overall drugs expenditure, but high spending practices spent significantly more on asthma drugs. CONCLUSIONS: Pressure to reduce the cost of asthma prescribing may lead to a lowering of the ratio of prophylactic to bronchodilator treatments. However, reducing prophylactic prescribing would run contrary to the British Thoracic Society guidelines and might worsen the quality of asthma care.

Administration, Topical↗
PubMed2005

An evaluation of a morphine public health programme for cancer and AIDS pain relief in Sub-Saharan Africa.

BACKGROUND: Despite growing HIV and cancer prevalence in Sub-Saharan Africa, and WHO advocacy for a public health approach to palliative care provision, opioid availability is severely limited. Uganda has achieved a morphine roll-out programme in partnership with the Ministry of Health. This study aimed to evaluate that programme by identifying challenges to implementation that may inform replication. METHODS: A multi-methods protocol appraised morphine regulation, storage, prescribing, and consumption in three phases: key informant interviews throughout the opioid supply chain, and direct observation and audit of clinical practice. RESULTS: Regulation had achieved its goal of preventing misuse and leakage from the supply chain. However, the Government felt that relaxation of regulation was now appropriate. Confusion and complexity in storage and authorization rules led to discontinuation of opioid pain management at the patient level and also wasted service time in trying to obtain supplies to which they were entitled. Continued neglect to prescribe among clinicians and public fear of opioids led to under prescribing, and clinical skills showed some evidence of need for improvement with respect to physical assessment and follow-up. CONCLUSION: The Ugandan programme offers a successful model for both advocacy and Governmental support in achieving opioid roll-out across health districts. Despite initial concerns, abuse of opioids has not been evident. Further work is required to ensure that available supplies of opioids are prescribed to those in need, and that clinical standards are met. However, the programme for roll-out has proved a useful model to expand opioid availability as the first step in improving patient care, and may prove a useful template for other Sub-Saharan African countries.

Acquired Immunodeficiency Syndrome↗
PubMed2002

More of the same is not enough.

Growth in pharmaceutical expenditures in Canada is approximately double the rate of growth in other healthcare expenditures. Conventional approaches to controlling expenditures are not working. The policy options proposed by Laupacis, Anderson and O'Brien for managing pharmaceutical budgets--better evidence, better dissemination, additional regulation and increased dialogue--are necessary but not sufficient to bring about more cost-effective prescribing. This paper suggests three additional strategies that will complement existing policies: restructuring consumer co-payments such that consumer cost-sharing varies inversely with therapeutic necessity; introducing physician budgets for those pharmaceuticals for which there is reasonable suspicion of overuse; and price-volume contracting with pharmaceutical firms, consistent with evidence from pharmaco-economic evaluation. The first strategy will send better signals to the consumer as to the value of the pharmaceuticals they are consuming. The latter two strategies will provide incentives for physicians to prescribe and industry to market their pharmaceuticals in a fashion more consistent with cost-effective use of these drugs. Better evidence and better dissemination are simply not enough.

Budgets↗
PubMed2002

Look beyond budgets to the broader benefits.

The success of researchers in developing innovative and effective medicines has produced a healthier and older population, as well as an observable shift in expenditure towards pharmaceuticals. In contrast to drug expenditures, patented drug prices have actually shown an average annual decrease of 0.5% since 1988. While we agree cost-effectiveness evaluation is a useful input into the decision-making process of drug benefit managers, it is but one consideration, and it is imperative that governments look beyond drug budgets to the broader benefits of innovative drug therapy to Canadians, both economically and clinically. The lead paper makes a number of suggestions regarding clinical trials that would lead to an increased demand on the developers of innovative medicines, all of which would raise the development costs of drugs while reducing the spectrum of available agents. This commentary argues that focusing greater attention on ensuring the appropriate use of medicines, with less concentration on restricting Canadians' access to effective drugs available in other countries, will yield the greatest benefits to the health of our population. Patient health management is a strategy that deserves a closer look to achieve this goal.

Budgets↗
PubMed1999

Positive impact of a follow-up phone call to community pharmacies in a medicaid drug utilization program.

OBJECTIVE: To evaluate the impact of including community pharmacists in strategies to alter excessive prescribing of antiulcer medications (AUMs) in a statewide drug utilization review (DUR) program. Mailing educational materials to physicians is a common intervention strategy of retrospective DUR programs. However, pharmacists are typically left out of this process, ignoring a possibly influential healthcare provider. METHODOLOGY: Patients without gastroesophageal reflux disease who received > or = 1.0 normalized therapeutic equivalents (e.g., 1.0 NTE = ranitidine 300 mg/d or omeprazole 20 mg/d) for five of six prior months were included. The pharmacists and physicians of these patients were divided into one of three geographically distinct groups: group 1 physicians received mailed materials only (pharmacists were not contacted); group 2 physicians and pharmacists received mailed materials only; and group 3 physicians and pharmacists received mailed materials, and the pharmacists were contacted by phone. Mean NTE and AUM costs were analyzed six months before and six months following the intervention. RESULTS: One hundred thirty-eight, 329, and 248 patients were included in G1, G2, and G3, respectively. There was a 12.4%, 8.0%, and 14.0% reduction in NTE for G1, G2, and G3, respectively. G1 AUM cost decreased 7.7% ($7710); G2 decreased 6.8% ($14 037); G3 decreased 20.5% ($26722). The total decrease in AUM cost for the entire cohort from before to after the intervention was $48469 (p < 0.05) in the six months following the intervention. CONCLUSIONS: A follow-up phone call to pharmacists in a statewide DUR intervention enhances the effectiveness of DUR interventions under the conditions studied. Enlisting the support of community pharmacists may improve the cost savings of these interventions.

Anti-Ulcer Agents↗
PubMed2002

Unlicensed and off-label drug use in an Australian neonatal intensive care unit.

OBJECTIVES: To determine the extent of unlicensed and off-label drugs prescribed in the level 3 neonatal intensive care unit (NICU) at the Royal Women's Hospital, Melbourne, Australia. METHODS: A prospective cohort study was conducted of all infants who were admitted to the NICU during a 10-week period. Each drug prescribed was evaluated in relation to the licensed approved uses to determine whether the drug was administered in a licensed manner or was unlicensed or used in an off-label manner. RESULTS: There were a total of 101 admissions involving 97 infants. A total of 1442 prescriptions were administered; 42% were licensed, 11% were unlicensed, and 47% were off-label. Twenty-one percent were off-label for 2 or more reasons. Eighty percent of infants received either an unlicensed or an off-label prescription or both; this proportion rose to 93% of extremely low birth weight infants. CONCLUSIONS: This is the largest study performed of unlicensed and off-label drug use in the NICU. This practice remains widespread despite clear recommendations to improve this undesirable situation. The attendant risks to infants and prescribers remain. It is time for legislation to be introduced to govern this area.

Age Factors↗
PubMed2006

Utilization and drug cost outcomes of a step-therapy edit for generic antidepressants in an HMO in an integrated health system.

OBJECTIVE: Antidepressants do not differ significantly in their ability to treat depression. Excluding the tricyclic antidepressants (TCAs), these drugs also do not differ significantly in their incidence of adverse events. Therefore, the initial choice of antidepressant medication should be based, in part, on cost. The objective of this study was to evaluate the impact on utilization and costs of a generic steptherapy edit for antidepressant drugs excluding TCAs in a health maintenance organization (HMO) in an integrated health system (IHS). METHODS: The pharmacy department of the 440,000-member HMO in an IHS collaborated with the Behavioral Health Clinical Program to design an intervention that required generic antidepressants as first-line pharmacotherapy. Under the GenericStart! Program, a brand-name antidepressant was covered only after trial with a generic antidepressant, excluding TCAs. A step-therapy edit was added to the pharmacy claims processing system on January 1, 2005. All new starts, defined as members with no claims history of antidepressant treatment within the preceding 6 months, were required to use a generic antidepressant. The member copayment was waived for the first prescription. All generic antidepressants were in tier 1 of the drug formulary, with an average copayment of $5 to $10. All brand-name antidepressants were in either tier 2 (preferred brand), with an average copayment of $20 to $25 or 25% coinsurance, or tier 3 (nonformulary brand), with an average copayment of $40 to $45 or 50% coinsurance. Pharmacy claims data from a national pharmacy benefit manager (PBM) without interventions for antidepressants in 2004 or 2005 were used for the comparison group. RESULTS: The generic antidepressant dispensing rate increased by 20 points (32.5% to 52.5%) in the intervention group but only 7.4 points (24.9% to 32.3%) in the comparison group in 2005 compared with 2004. The principal measure of antidepressant drug cost per day of therapy in the intervention group decreased by 11.7% (from $2.40 to $2.12) in 2005 compared with 2004 versus a 2.7% decrease (from $2.60 to $2.53) in the comparison group (P <0.001). Days of antidepressant drug therapy per member per month (PMPM) dropped by 1.5% (from 1.74 to 1.71) in the intervention group versus a decrease of 5.0% (from 1.37 to 1.30) in the comparison group in 2005 compared with 2004. The combination of change in drug cost and utilization resulted in a 13.0% decrease in antidepressant drug cost, from $4.16 PMPM in 2004 to $3.62 in 2005, compared with a 7.6% decrease (from $3.57 to $3.30 PMPM) in the comparison group. The 9.0% difference in drug cost per day represents drug cost savings of approximately $0.36 PMPM or $1,880,562 in 2005 dollars for this HMO of approximately 440,000 members. CONCLUSION: A step-therapy edit requiring HMO members to use a generic antidepressant, excluding tricyclics, prior to use of a brand-name antidepressant resulted in drug cost savings of 9.0% for the entire class of antidepressants, equal to $1,880,562 ($0.36 PMPM) in 2005 dollars in the first year of the intervention. A small (-1.5%) decrease in use of antidepressants occurred in the intervention group, which was less than the 5.0% decrease in utilization of antidepressants in the comparison group.

Antidepressive Agents↗
PubMed1995

Use and abuse of benzodiazepines in Hong Kong 1990-1993--the impact of regulatory changes.

To control benzodiazepine abuse in Hong Kong, the Government's Pharmacy and Poisons Board reclassified benzodiazepines as Dangerous Drugs in October 1990. Apart from formal prescriptions, detailed records were then required for the supply and dispensing of these drugs. These regulations were applied initially only to brotizolam, triazolam and flunitrazepam, and were extended in January 1992 to include all benzodiazepines. The impact of these regulatory changes on benzodiazepine use has been studied by analyzing the sales patterns of seven benzodiazepines between 1990-1993. In 1991, the sales of flunitrazepam and triazolam fell, but the sales of five unrestricted benzodiazepines increased. In 1992-1993, the sales of all but one of the benzodiazepines fell. Comparing 1993 to 1990, the fall in sales was particularly marked for triazolam, chlordiazepoxide and flunitrazepam. A regulation requiring the use of proper prescriptions and detailed records for the supply and dispensing of benzodiazepines, appears to have curbed, at least partially, their abuse in Hong Kong.

Benzodiazepines↗
PubMed2004

Taking the physician out of "physician shopping": a case series of clinical problems associated with Internet purchases of medication.

In the United States, psychoactive prescription medications rank second only to marijuana as drugs of abuse (if tobacco and alcohol are discounted). Physician shopping--visiting multiple physicians simply to procure prescriptions--has been a traditional method for acquiring drugs illicitly. As community-based efforts to curtail physician shopping have expanded, drug abusers have turned increasingly to the Internet. Illegal Internet pharmacies, increasing rapidly in number during the past decade and requiring neither prescription nor physician oversight, offer minimal interference to obtaining drugs. With no physician involved, patients cease to be patients. Instead, they become consumers able to buy prescription medications, even controlled substances, from anonymous providers offering no ongoing treatment relationship and taking no responsibility for the drugs dispensed. When complications occur, these consumers become patients, turning back to the traditional medical system to manage overdoses, addictions, and drug adverse effects and interactions. We present a case series illustrating some of the medical problems that resulted from drugs bought on-line illegally.

Adult↗
PubMed1995

Multidimensional work sampling in an outpatient pharmacy.

Multidimensional work sampling was performed at a hospital-based outpatient pharmacy. Data were collected from nine full-time and five part-time pharmacists over a 45-day baseline period. Pharmacists wore silent, random-signal generators that permitted continuous work sampling. We introduced the concept of quick codes to allow pharmacists to record their work using a single letter for repetitive activities. Pharmacists recorded 4,687 observations, 90 percent using quick codes. The most common activity was checking prescriptions (36.2 percent). Detection and correction of prescribing errors was the most common reason for their work (39.4 percent). Most work-related activities were performed alone (80 percent) with little time in contact with patients or physicians. These baseline measures will be compared with future measures to assess the effect of the implementation of computerized prospective drug utilization review and clinical treatment guidelines on pharmacists' work. It is expected that these technologic and process changes will increase opportunities for pharmacists to educate patients and consult with physicians.

Classification↗
PubMed1995

An evaluation of postoperative pain management in pediatric patients at a university teaching hospital.

In recent years, pediatric pain management has begun to receive some much deserved attention. Many misconceptions regarding pediatric pain management have resulted in infants and children receiving inadequate pain control after surgical or invasive procedures. The purpose of this investigation was to evaluate appropriateness of pain management practices, emphasizing drug therapy, in children with acute pain after a surgical procedure. Analgesic use and pain assessment methods were evaluated for 30 pediatric patients undergoing an invasive medical procedure or surgery. Data were collected concurrently on the use of pain medications, potential for drug interactions/duplication of therapeutic classes, pain assessment, patient response to medication, and any adverse effects experienced by a child. Twenty patients (67%) had concurrent orders written for multiple analgesics on admission to the nursing unit. Only 6 of these 20 order sets (30%) designated specific indications for use. Ten of the 14 remaining order sets (those without specific directions for use) contained at least one medication that was inappropriate to treat the expected level of postoperative pain. Fifty-four percent of total physician orders fell outside study criteria for appropriate dosing and scheduling frequency. Patient records revealed that nursing administered the lowest ordered dose 47% of the time, and a failure to consistently conduct pain assessments or document patient response to medication. Eight patients (27%) experienced allergic-type reactions, whereas 7 patients (23%) experienced adverse drug reactions. Information gathered from this review will be used to determine if a need exists to develop hospital guidelines or adopt the Agency for Health Care Policy and Research guidelines for acute pain management in children.

Analgesics↗
PubMed1997

Considerations in pharmaceutical conversion: focus on antihistamines.

The practice of pharmaceutical conversion, which encompasses three types of drug interchange (generic, brand, and therapeutic substitution), is increasing in managed care settings. Pharmaceutical conversion has numerous implications for managed care organizations, their healthcare providers, and their customers. Although drug cost may be a driving consideration in pharmaceutical conversion, a number of other considerations are of equal or greater importance in the decision-making process may affect the overall cost of patient care. Among these considerations are clinical, psychosocial, and safety issues; patient adherence; patient satisfaction; and legal implications of pharmaceutical conversion. Patient-centered care must always remain central to decisions about pharmaceutical conversion. This article discusses the issues related to, and implications of, pharmaceutical conversion utilizing the antihistamines class of drugs as the case situation.

Automobile Driving↗
PubMed2001

Prescribing practices of consultants at Karachi, Pakistan.

OBJECTIVE: To audit the prescribing practices of consultants. DESIGN: A randomized sample survey of 354 consultants prescription for analysis of some basic parameters as recommended by World Health Organization (WHO). MAIN OUTCOME MEASURES: To provide feedback to the prescribers for promoting rational drug therapy. RESULTS: The average number of drugs for prescription were found to be 4.51 and the average daily cost of prescribed drugs was Rs: 133.41. The antimicrobials, vitamins/minerals and injections were over-prescribed. About half of the prescribed drugs were from the National Essential Drugs List of Pakistan (NEDLP) and only a little over 12% were prescribed by their generic names. CONCLUSIONS: The prescribing practices of the consultants in Karachi are rather liberal and not rational. Overuse of antimicrobials and injections have been observed and there is general tendency of indulging in polypharmacy requiring continued medical education.

Anti-Bacterial Agents↗
PubMedDate not supplied

An audit of prescribing practices in health care facilities of the Wassa West district of Ghana.

While many health districts recognise that irrational prescribing leads to wastage of drugs, few monitor prescribing practices. We investigated drug use in government health facilities in the Wassa West district of Ghana. Retrospective prescribing data were obtained from 700 outpatients' clinical record cards in 7 government health facilities in the district. Prescribing patterns were significantly worse in the health centres than in the district hospital in terms of polypharmacy, use of injectable drugs and antibiotics. Overall, 4.8 drugs were prescribed per patient, 97% of drugs were on the national essential drugs list and 65% of drugs were prescribed by their generic names. Antibiotics and injectable drugs were prescribed for 60% and 80% patients respectively. The observed patterns were related to the cadre of prescribers, availability of diagnostic facilities, participation in recent refresher training and patient demand. Measures to improve prescribing practices are discussed.

Ambulatory Care↗
PubMed2002

Rational drug use in Cambodia: study of three pilot health centers in Kampong Thom Province.

This study obtained baseline information for the design of a strategy to address irrational prescribing practices in three health centers in Kampong Thom Province, Cambodia. Indicators of rational drug use have been measured and compared with Standard Guidelines. Data were collected from patients' registers and by interviewing patients immediately after patient-prescriber and patient-dispenser encounters. Checklists and pre-designed forms were used to collect data regarding the World Health Organization drug use indicators and some additional indices. Of the 330 prescriptions analyzed, the results showed that the average number of drugs per prescription was 2.35 and that a large proportion of the prescriptions contained two or more drugs that could result in adverse drug interactions. Prescribing by generic names (99.8%) was encouraging. The exposure of patients to antibiotics (66% to 100%) was high, and injection use (2.4%) was often unnecessary. Prescribing from the Essential Drugs List (99.7%) was satisfactory. The average consultation and dispensing times were short and not sufficient for patients to get health information. All the prescribed drugs were supplied, but all were inadequately labeled. Some 55% of patients knew the correct dosage of their drugs. The availability of key essential drugs (86.6%) was below the Standard. The percentages of appropriate prescriptions for treating malaria, diarrhea and acute respiratory infection treatment were 68.3%, 3.3%, and 45%, respectively. Inappropriate prescriptions were mostly due to unsuitable dosages, incorrect drugs, and the improper duration of treatment. The results suggest a need for intervention to curb the irrational use of drugs in prescribing at the three pilot health centers. Continuing education of prescribers and healthcare providers, monitoring, supervision, public education would be beneficial.

Cambodia↗