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PubMed1991

The end of mandatory retirement and its implications for academic medicine.

The prohibition against age-based mandatory retirement, codified in amendments to the Age Discrimination in Employment Act (ADEA) in 1986, remains a concern in the academic medical community. A seven-year exemption covering tenured faculty expires at the end of 1993. The author reviews the legislative history of the ADEA and explores in detail the planning and management issues--and the available projections of likely faculty behavior in the future--concerning the banning of age-based mandatory retirement of higher education faculty, with special reference to the academic medical community. Although the major studies concerning the probable course of events after the seven-year exemption expires indicate that there will not be a cataclysmic effect on institutions of higher education, it is still not certain how tenured faculty will behave and how that will affect medical schools. The author cautions that the management acumen of institutional leaders will be taxed, and that medical school deans should realize this and begin the transition into the new era by improving systems for faculty evaluation and development, clarifying the financial guarantees of tenure, implementing space utilization reviews, and developing programs to make retirement attractive.

Aged↗

PubMedDate not supplied

Assessing the appropriateness of physician prescribing for geriatric outpatients. Development and testing of an instrument.

OBJECTIVE: In a randomized, controlled trial evaluating the impact of clinical pharmacists' consultations on physicians' prescribing decisions, a seven-member physician/pharmacist panel developed an instrument to characterize and quantify the full range of drug-prescribing problems. The instrument was tested for validity and reliability. SAMPLE: The instrument was applied in reviewing prescribing for 236 geriatric outpatients. METHODS: To ensure internal validity of the instrument, five panel meetings were devoted to reaching a consensus on procedures, categories, criteria, and scoring. Each case was evaluated independently by two reviewers and each drug in the regimen was evaluated for drug-drug interactions, dosage, schedule, allergic reactions, therapeutic duplication, use of drugs without established diagnoses, and inappropriate drugs for the patient's clinical conditions; discrepancies were adjudicated by the panel chairperson. Self-reported adverse effects of 60 study patients who were interviewed, and hospital readmissions of all study patients were used to test the external validity of the instrument. RESULTS: Inter-rater reliability improved over time, reaching a high of 97.1 percent after six months. A positive association was determined between the prescribing scores and the number of reported adverse effects (rho = 0.28, p = 0.02). Although the number of patients with drug-related hospital readmissions was too few to establish a significant association between the prescribing scores and readmissions, the findings were expected. CONCLUSIONS: Given current requirements for drug utilization reviews in hospitals, health maintenance organizations, and Medicaid programs, this instrument may prove to be very useful.

Aged↗

PubMed1995

Ethical cautions in the use of outcomes for resource allocation in the managed care environment of mental health.

Increasingly, resources are being allocated through competitive contracting based on outcome data. This context for outcome research renews ethical concern about the nature of outcome data in the field of mental health. The epistemology of mental illness creates special concerns regarding outcome measurement. Ethical cautions specific to six types of outcome measurement are reviewed: utilization, clinician reports, patient reports, objective measures of diagnostic entities, objective measures of functioning and multifactor research. Brief guidelines are offered for addressing ethical cautions. Also discussed are the difficulty in defining good outcomes and a social obligation to future generations that may be better addressed through process measurements.

Contract Services↗

PubMed2006

Learning and utilization of generic skills by practitioners in the field of clinical laboratory science/medical technology.

OBJECTIVE: To determine whether and to what extent generic skills that are learned by practitioners are used on their clinical laboratory science/medical technologist (CLS/MT) jobs; and to determine if there are any significant differences in learning and/or using these skills by practitioners who were CLS/MT vs. Other BA/BS degree majors. DESIGN: In the field (ITF) laboratory practitioners were surveyed as to whether or not they: 1) were CLS/MT program graduates; 2) utilized the following generic skills in their jobs: analytical reasoning, communication, computer use, data correlation, decision making, precision studies, problem solving, quality assessment, supervision, teaching, technical writing, troubleshooting, research and utilization review; 3) learned these skills as students or practitioners. SETTINGS AND PARTICIPANTS: Data were collected from 515 CLS/MT ITF participants who were part of an ongoing longitudinal study. MAIN OUTCOME MEASURES: Participants were asked if they were CLS/MT program graduates; whether they used the skills frequently, sometimes, rarely or never; and whether they initially learned the skills as students or developed them on the job (OTJ). Chi square analyses were performed to test for differences among groups. RESULTS: The response rate was 44%. Frequencies for using the skills were generally over 90% with three exceptions reported as rarely or never used by the majority of the respondents, and two exceptions reported as being approximately equally used or not used by the respondents. A sizable minority (23% to 45%) of the sample reported never learning six of the skills. Significant (p < 0.05) chi square results occurred between learning and utilizing the following skills: computer use, participation in research, problem solving, supervision, technical writing and utilization studies. Although a consistently higher proportion of the CLS/MT graduates reported learning the skills as students and Other BA/BS graduates reported learning them OTJ, no significant differences between these sub-groups were observed for either learning or using these skills. CONCLUSION: For this sample group, most generic skills learned as CLS/MT students and/or practitioners are applied to the ITF jobs and are generally congruent with what is being taught in CLS/MT programs. However, there are some notable exceptions.

Clinical Competence↗

PubMed1984

Evaluation of amitriptyline use for depression when prescribed by internists and psychiatrists.

The efforts involved in structuring and implementing a drug utilization review (DUR) program that was designed to assess the use of amitriptyline for depression when prescribed by internists and psychiatrists is described. In-depth audit criteria were used to identify deviations from the criteria for each group. An immediate goal of this amitriptyline DUR program is to apply the results of the study toward the implementation of a targeted, multifaceted educational program. The design of the DUR program should emphasize the individual needs of each of the two study groups.

Amitriptyline↗

PubMed1991

Words without action? The production, dissemination, and impact of consensus recommendations.

When existing evaluations find little or no evidence of consensus recommendations leading to action, one can justifiably ask why so much of this review was dedicated to analyzing alternative ways of producing such "words without action." There are, however, at least two reasons why consensus recommendations should be produced with care and attention to validity. First, recommendations do sometimes have an impact on behavior as a consequence of mere dissemination activity--the Dutch program, for instance, was more successful than most. This success may occur when the target audience is already particularly receptive to change and the message is timely and delivered by a credible source in a clinically relevant way. Thus, although "such a conjunction of favorable conditions is probably the exception rather than the rule for consensus topics" (46, 240) it does happen. Second, the output from consensus processes is increasingly a potential input to other processes. Consensus recommendations can be used as the criteria for evaluation and appraisal aimed at changing practice behavior, making administrative decisions on resource allocation, or defining research protocols. For instance, quality assurance activities, such as peer assessment, practitioner certification, or utilization review, are actively seeking criteria with which to make judgments and elicit changes in practice to improve the quality of care. Funding agencies are looking for information to help make reimbursement, capital expenditure, or fee-for-service decisions on cessation of insurance for particular procedures or approaches. These uses of the consensus criteria are potentially major and controversial. Therefore, even if dissemination rarely leads to action, consensus processes should still be done carefully and with valid techniques. The use of their recommendations embedded within other activities may well lead to (forced) changes in behavior. On ethical grounds alone, we should be as sure as possible that the behavior changes being implied and encouraged are indeed advisable. For these reasons, the review describes the decision points in the production process for consensus recommendations as a start on the development of a set of recognized standards. The review offers a critical appraisal of the various methodological choices available at each decision point. The seven decision points are selecting a topic, picking the consensus group, providing background preparation, identifying information inputs, choosing a group judgment process, defining the criteria for recommendations, and choosing a report preparation procedure and format. At least two important points emerged from this review. First, the research is often not well enough developed to give clear indications for many of the choices on what is the "best" alternative.(ABSTRACT TRUNCATED AT 400 WORDS)

Canada↗

PubMedDate not supplied

Hyperthyroidism in adults: variable clinical presentations and approaches to diagnosis.

BACKGROUND: Hyperthyroidism is a disease that has various symptoms and can present in many ways. In the elderly patient hyperthyroidism often is not expressed in the classical manner. A case report of a middle-aged man who had hyperthyroidism with only one symptom is detailed. METHODS: A literature review utilizing MEDLINE files from 1988 to the present, as well as current textbooks of medicine and endocrinology, was used to prepare this report. Keywords for the search were "hyperthyroidism," "symptoms," "unintentional weight loss," and "differential diagnosis." RESULTS AND CONCLUSIONS: The clinical presentation of hyperthyroidism can vary from almost asymptomatic to apathetic in appearance to a marked hyperdynamic physiologic response. Family physicians must be well informed of this variation in disease expression. Overlooking the diagnosis of this relatively easily treated condition can be detrimental to patient care and expensive.

Adult↗

PubMed1997

Serotonin reuptake inhibitors and the adequacy of antidepressant treatment.

OBJECTIVE: To determine whether the use of serotonin reuptake inhibitors (SSRIs) improves antidepressant medication prescribing patterns for both psychiatric and non-psychiatric physicians. DATA SOURCES/SETTING: Drug utilization review of 4,103 prescriptions for antidepressant medications with patients diagnosed with depressive disorders over an eighteen-month period from the formulary records of a large insurance company. DESIGN: Using standards developed for clinical guidelines, variation in trial and treatment adequacy between drug types and physician specialty was studied. PRINCIPAL FINDINGS: Thirty-five percent of initial antidepressant trials were not prescribed for an adequate duration or at an adequate dosage level. SSRIs were more likely to be prescribed adequately than any other antidepressant reviewed. Psychiatrists were more likely to prescribe antidepressants at an adequate dosage level, whereas non-psychiatric physicians were more likely to attain adequate duration of treatment. CONCLUSIONS: A greater reliance on SSRIs may increase the likelihood of maintaining adequacy in antidepressant treatments. Although higher in cost than other treatment choices, their lower side effect profile is likely to maximize patient satisfaction and physician and patient adherence to guidelines. In order to ensure effective and efficient antidepressant usage, such patterns must be identified and appropriate performance improvement strategies (e.g., Total Quality Improvement, critical pathways) may be employed.

Antidepressive Agents↗

PubMed1987

Impact of a therapeutic drug monitoring program for digoxin.

Although numerous utilization reviews of serum digoxin assays have demonstrated the positive impact of therapeutic drug monitoring, to our knowledge, the question of whether the withdrawal of such a program would reverse the effect has not been addressed. The current study employed a prospective, randomized, crossover design to evaluate this question and document the cost savings. There were 196 serum digoxin assays performed in the 207 patients. It was found that a continuous therapeutic drug-monitoring program was warranted since, after its withdrawal, there was a deterioration in audit criteria performance. Reimplementation of the therapeutic drug-monitoring program resulted in a significant decrease in the average number of assays requested per patient (from 1.41 to 0.73) and an improvement in audit criteria performance.

Canada↗

PubMed1989

The provision of home health care services through health maintenance organizations.

The vast majority of the HMOs responding to the survey in this study use home health care as a substitute for acute inpatient hospitalization, contract out for services with community-based home health agencies, reimburse on a discounted fee-for-service basis, and use prior authorization and concurrent review as the primary methods to control the use of home health care. These findings suggest that HMO home health care services mirror the inadequacies of Medicare home health care in that they are acute care-focused and not intended to fill the supportive and maintenance care needs of the chronically ill elderly. HMOs, however, are typically more flexible in their service provision than is Medicare. Need for home health care is determined primarily on prospective, case-by-case evaluations of cost effectiveness, not on retrospective determinations based on strict, and sometimes arbitrary, guidelines and limitations. This, however, does raise some important issues for access and quality and for the relationship between HMOs and home health agencies. Is cost containment the only legitimate reason for providing home health care? Should home health care be used solely as a substitute for acute inpatient hospitalization? Where does the locus of authority lie for deciding coverage of home health care services? This study uncovered several issues related to the provision of home health care in HMOs that created conflict and uncertainty for all parties. These issues included: conflicting roles for HMOs, whether to provide services internally or externally, contracting between HMOs and home health agencies, the locus of authority for utilization review, the role of physicians, quality assurance, and perceived problems with the Health Care Financing Administration. HMOs are often perceived as failing to do an adequate job of providing home health care services because of the difficulty in satisfying conflicting considerations in three key areas: whether home health care should be focused on cost containment or meeting unmet needs, whether home health care should be focused on acute or long term care, and the unrealistic expectations patients and providers have of HMOs. HMOs primarily provide home health care in an effort to contain costs, particularly by using home health care to substitute for inpatient hospitalization. While HMO representatives acknowledge the importance of home health care in improving the patient's and family's quality of life by providing supportive or chronic maintenance care, the use of home health care for this purpose is generally not allowed by HMOs.(ABSTRACT TRUNCATED AT 400 WORDS)

Acute Disease↗

PubMed1997

Rapid depletion of plasma tryptophan: a review of studies and experimental methodology.

Evidence that the neurotransmitter serotonin (5-hydroxytryptamine, 5-HT) plays a role in the pathophysiology of mood disorders has been accumulating over the past three decades. Recent studies on this neurotransmitter have extended across the spectrum of psychiatric disorder, suggesting a role for 5-HT in psychosis, aggression, eating disorders and addiction. However, much of the evidence has come from post-mortem examination of the brain or measures of peripheral rather than central 5-HT function. The technique of tryptophan depletion allows investigation of brain 5-HT function in living subjects by examining the behavioural responses to this pharmacological challenge. This review considers the current status of tryptophan depletion as an experimental technique and discusses the implications of findings both in affective disorders and in a range of other psychiatric syndromes. MEDLINE and PSYCHLIT searches were completed for the years 1966 to November 1996 using the key words 'serotonin', '5-hydroxytryptamine', 'tryptophan' and 'depletion'. In addition relevant journals were hand-searched for the period from 1980 to December 1996. Forty-four double-blind studies in humans and three clinical case reports were identified; these cover a range of psychiatric disorders including mood disorders and psychoses, anxiety and eating disorders and specific behaviours such as appetite, aggression and craving. The studies reviewed utilized a variety of differing methodologies reducing the extent to which results can be generalized. A series of studies in depressed patients (before and after treatment with antidepressants) and their first-degree relatives have shown the importance of an intact 5-HT system in the action of antidepressants and offer new insights into the biology of affective disorder. The mood change induced by tryptophan depletion may predict those patients likely to respond to 5-HT-specific drugs. Rapid tryptophan depletion has also been reported to exacerbate both panic and aggression in vulnerable individuals. Effects in other disorders are conflicting and further research is needed to clarify these findings.

Bipolar Disorder↗

PubMed2005

Optimizing fluoroquinolone utilization in a public hospital: a prospective study of educational intervention.

Fluoroquinolone (FQ) utilization should be optimized, with the aim of controlling both multidrug-resistant bacteria and costs. In the present study, the appropriateness of FQ prescriptions for urinary tract infections (UTIs) before and after an educational intervention was examined prospectively. FQ-prescribing physicians received oral and written guidelines between the two phases of the study. All patients admitted to Saint-Antoine University Hospital (Paris) and treated with FQs for UTIs during the study period were included. The main outcome measures of the appropriateness of FQ prescriptions were based on the principles of Antibiotic Utilization Review. The study involved 127 patients. The main prescribing errors before the intervention were wrong routes of administration and failure to take into account antibiotic susceptibility results. The rate of erroneous prescriptions fell by 74.4% after intervention. About 71% of the improvement can be attributed to the intervention (71.4%; 95% confidence interval, 39.3-86.8). The intervention had an overall positive impact on FQ prescription quality. The decrease in inappropriate prescriptions was due mainly to the use of antibiotic susceptibility results (23% vs. 11.5%, P<0.05) and better consideration of indications (18.9% vs. 3.8%; P<0.05). Future educational interventions will cover other indications and will take into account costs and local antimicrobial susceptibility patterns.

Administration, Oral↗

PubMed1982

Utilization of antibiotics: analysis of appropriateness of use.

An antibiotic utilization review was performed for the purpose of determining the frequency and types of infectious diseases presenting to a large, teaching hospital emergency department, and the appropriateness of the use of antibiotics in this setting. In 27% of the visits a diagnosis of an infectious disease was made or an antibiotic was prescribed. The most common presenting diagnoses (comprising more than 75% of cases) were infections of the respiratory tract, skin, urogenital system, and gastrointestinal tract. Penicillins and sulfonamides were frequently prescribed in nearly two-thirds of cases. Antibiotic prescribing was determined to be appropriate in 78% of cases. Inappropriate use most often involved the use of prophylactic antibiotics in clean lacerations and the use of prophylactic antibiotic combination products following trauma to the eye.

Adolescent↗

PubMedDate not supplied

Clinical pharmacists' impact on prescribing in an acute adult psychiatric facility.

An analysis is presented of data collected to evaluate the impact of a clinical pharmacy service on an acute psychiatric admitting unit. Retrospective longitudinal drug utilization reviews (RLDUR) were performed one year apart (pre- and post-implementation of services) on the same treatment team. Process measures significantly affected include (percent reduction): total drugs/patient (33.9), number of antipsychotic drugs/patient (38.0), number of anticholinergics started on admission/patient (53.2), and number of doses/patient/d (42.4). Other drug-use parameters significantly affected include: a 42-percent increase in the mean dosage expressed as chlorpromazine equivalents, and a 47-percent reduction in the number of patients on low potency antipsychotic medications. Beneficial outcome was reflected by a faster rate of discharge or transfer to a less restrictive ward environment in the pharmacy study population. The study population also demonstrated a 55.8-percent decrease in their readmission rate to the facility over a one-year follow-up period. Clinical pharmacy services positively affect both process and outcome health care measures.

Acute Disease↗

PubMed2001

Performance and quality measurement in occupational health services: current status and agenda for further research.

BACKGROUND: There is growing interest in evaluating the impact and effectiveness of occupational healthcare services (OHS). Managed care networks, case and disease management, worker health promotion, and utilization review services have proliferated in OHS, usually without scientifically based, objective measures of their impact on the quality of care, outcomes, or costs. Performance and quality improvement (QI) efforts in OHS are different from those in general health care because the population, range of conditions, setting of care, and primary outcomes of interest differ considerably. However, scientific knowledge resulting from the application of QI in general health care can provide a useful framework for the development of measures in OHS. METHODS: We describe the development, selection, and evaluation of OHS performance and quality measures, and propose a research agenda. CONCLUSIONS: Quality and performance measures in OHS should address common work-related conditions with high costs, suboptimal outcomes, or unclear parameters for ideal practices. They should reflect stakeholder priorities. Measures should be precise and quantifiable, clearly specified, reliable, valid, and sensitive to important changes. They should be based upon data that can be collected and analyzed at a reasonable cost and effort. The focus of measurement should be on situations where improvement can be achieved by those directly involved in OHS delivery, through defined approaches. Appropriate severity and case-mix adjustment may be especially problematic in OHS. Confidentiality, regulatory concerns, and appropriate use of results must be considered in the development and use of OHS measures. Research is needed to identify, develop, and validate OHS-specific measures, to establish risk adjustment methods, and to test the utility of this information in improving OHS.

Health Policy↗

PubMed1988

An examination of histamine-2 receptor antagonist use by Medicaid recipients in Wisconsin long-term care facilities.

The Wisconsin Drug Utilization Review Project used Medicaid claims data to examine the use of long-term, full doses histamine-2 receptor antagonists (H2RAs) among long-term care facility (LTCF) residents, ie, doses exceeding 800 mg per day of cimetidine or 150 mg per day of ranitidine for 12 weeks or more. Additional information about a small but representative sample of patients was obtained from consultant pharmacists by mail questionnaire. Of approximately 35,000 residents, there were 1,046 receiving long-term, full-dose H2RAs during 1984 at a cost of +405,848. No differences were noted between treated patients and the overall LTCF population by gender, age, level of care, or geographic locality. Among 387 patients receiving therapy for the last 3 months of 1984, over one half received antacids and over 20% received nonsteroidal anti-inflammatory drugs concurrently. According to survey respondents, almost one half of the patients had no diagnosis amenable to treatment by H2RAs. Diagnostic procedures conducted within 30 days prior to the initiation of H2RAs were hemoglobin/hematocrit assessment (performed on 53% of patients), stool testing (34%), radiological exam (23%) and endoscopy (8%). The results suggest that there is widespread use of long-term full-dose H2RAs in LTCFs for undocumented, inappropriate, and poorly supported diagnoses. Such findings are of concern to all persons charged with monitoring drug use in nursing homes because of the implications for both quality and cost of care. Information from this study will be used in designing a program to reduce inappropriate utilization of H2RAs, and Medicaid claims data will be used to monitor trends in utilization.

Aged↗

PubMed1985

Evaluation of appropriateness and interpretation of serum theophylline assays.

A drug utilization review of serum theophylline assays was undertaken to: (1) evaluate the prescribers' usage and interpretation of serum theophylline levels (STLs), and (2) calculate the cost of inappropriate assays. Criteria for appropriate use and interpretation were defined by an audit committee and approved by the chief medical resident. STLs were evaluated on medicine patients for a one-month period. Results of 102 levels ordered showed that 47 percent were inappropriate. The reasons cited most often for inappropriateness were: (1) previously-known STLs with no reason to expect a change in subsequent levels (26 percent); and (2) STLs drawn prior to steady state (12 percent). None of the levels evaluated had a request entered for the sampling time to be recorded. STLs were interpreted with the same degree of accuracy regardless of whether they were ordered appropriately. Results from this study suggest significant cost savings can be realized if physicians' ordering habits are corrected.

California↗

PubMed1985

Cost containment through therapeutic substitution of aminoglycosides.

A therapeutic substitution policy (TSP) for tobramycin and gentamicin sulfate was implemented at the University of Texas Medical Branch (UTMB). The policy was designed by various physician-chaired hospital committees and clinical departments that collaborated with the pharmacy service. The goal was to encourage the medical house staff to use the most economical yet safe and effective aminoglycoside, without limiting the medical team's prerogative to select among alternatives within this antibiotic group. Cost data from the first 6 months of aminoglycoside use under the new policy projected an annual savings of $139,071 in drug expenditures and $242,472 in patient charges. Following the implementation of the TSP, a concurrent drug utilization review (DUR) was performed in 50 consecutive inpatients prescribed amikacin, tobramycin, or gentamicin sulfate. The objectives were to identify those aspects of prescribing and monitoring of aminoglycosides by house staff that could be improved by specific policy and/or education, and to evaluate those specific cases in which attending physician's approval allowed house staff to prescribe an aminoglycoside other than designated in the TSP. The audit revealed that house staff were compliant with 72% of the DUR criteria; however, at least one instance (mean of 5.04 +/- 2.21) of noncompliance occurred during the treatment of each patient. The most frequently encountered deficiencies were failure to monitor for ototoxicity, incorrect orders for at least one set of serum aminoglycoside concentrations, and improper dosage adjustments for those patients with renal insufficiency. In three cases, the attending physician approved house staff use of tobramycin instead of gentamicin sulfate for reasons of organism resistance, pre-existing renal impairment, and long-term treatment of osteomyelitis.

Aminoglycosides↗