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PubMed2006

A European survey on the possibilities and obstacles of electronic prescriptions in cross-border healthcare.

This study investigated the possibilities and obstacles for cross-border electronic prescriptions within the European internal market. Cross-border electronic prescribing requires interoperability of the systems and use of standardized solutions. We conducted a survey-based case study. A questionnaire on the use of electronic prescriptions was sent by e-mail to the delegates from 14 European Union (EU) member countries and 2 European Economic Area (EEA) countries during spring-summer 2003. A reply was received from 11 delegates in 11 countries contacted. Currently electronic prescriptions are in everyday use in only a few EU member countries, while many others are running or considering pilot projects. We found that electronic prescribing across national borders is impeded by many obstacles, which may relate to other systems or to lack of standardization. Information technology is likely to gradually spread to prescribing in Europe. Before more countries will integrate electronic prescribing into national healthcare, it would be important to ensure interoperability and common standards between national systems. Only then can electronic prescribing offer its full potential, and cross-border electronic prescribing can be realized at the EU level.

Computer Communication Networks↗
PubMed2005

Repeat prescriptions: refill adherence in relation to patient and prescriber characteristics, reimbursement level and type of medication.

BACKGROUND: Repeat prescribing used in long-term pharmacotherapy is often associated with inadequate patient medication, including non-adherence. In this paper we explore patients' drug refill adherence with repeat prescriptions and relate refill data to patient age and gender, type of prescriber, type of prescribed drug, and reimbursement level. METHODS: During one week of 2002, copies of 3636 repeat prescriptions filled at 16 large Swedish pharmacies were collected. Satisfactory refill adherence was defined as dispensed refills covering 80-120% of the prescribed treatment time. Under- and oversupplying were defined as <80% and >120% coverage, respectively. RESULTS: The average level of refill adherence was 57%, and the level of under- and oversupplying 21% and 22%, respectively. There was no gender difference. Patients who were exempt from payment had higher oversupplies than others (33% versus 19%), and patients of general practitioners had higher refill adherence than patients of hospital physicians. The highest refill adherence was observed for contraceptives (81%) and the lowest for anti-asthmatics, proton pump inhibitors and non-steroidal anti-inflammatory drugs (30-40%). CONCLUSIONS: Refill non-adherence includes both under- and oversupplying and may vary due to different attitudes between prescribers and between patients. Different therapeutic indications and reimbursement systems are other apparent causes. These observations should be considered in programs aiming to assist patients in following medication prescriptions.

Adolescent↗
PubMed2004

Acute cough: a qualitative analysis of how GPs manage the consultation when patients explicitly or implicitly expect antibiotic prescriptions.

OBJECTIVE: The aim of this study was to analyse how GPs manage the consultation for acute cough when patients explicitly or implicitly expect antibiotic prescriptions. METHODS: A qualitative analysis of audio-taped consultations was carried out. The participants were eight GPs from eight general practices in Northrhine, Germany and their 42 patients with acute cough over a 2 week period. Three researchers analysed the consultations independently, finally agreed by discussion. RESULTS: Implicit expectations for antibiotics were found frequently, but in none of the 42 consultations was the patient asked directly what she or he expected in terms of therapy. The topic of expectations and demands itself normally was not discussed at all, not even in a non-direct manner. In some consultations, the possibility of an antibiotic prescription was ruled out by the GP from the beginning. In some consultations, even a 'pseudo-consent' was found, avoiding any explicit clarification. CONCLUSION: GPs seem to overestimate the actual pressure to prescribe antibiotics for acute cough. The (over) prescription of antibiotics might not be a question of knowledge but a lack of patient centredness.

Adolescent↗
PubMed2005

Effect of educational intervention on antibiotic prescription practices for upper respiratory infections in children: a multicentre study.

OBJECTIVES: To evaluate the impact of an educational intervention on judicious antibiotic prescription for upper respiratory diseases in children. METHODS: A multicentre before-and-after study was conducted in five major community child healthcentres in Israel. Antibiotic prescription data were collected for all visits of patients aged 3 months to 18 years with a diagnosis of acute otitis media, tonsillopharyngitis, sinusitis or upper respiratory tract infection from November 1999 through February 2000 (pre-intervention period) and from November 2000 through February 2001 (post-intervention period). The intervention consisted of a 1 day seminar on the diagnosis and judicious treatment of respiratory tract infections in children according to the recommendations of the Centers of Disease Control and Prevention. The patient files were reviewed for patient characteristics, specific respiratory disease, and specific antibiotics prescribed. The main outcome measures were the rates and appropriateness of antibiotic prescribing for the different respiratory diseases before and after an educational intervention for practising paediatricians. RESULTS: A total of 4580 clinic visits were eligible for analysis in the pre-intervention period and 4364 in the post-intervention period. From the pre- to the post-intervention period, the odds ratio for appropriate antibiotic treatment was 1.8 for acute otitis media (95% CI 1.52-2.11, P < 0.01) and 1.35 for pharyngitis (95% CI 1.13-1.61, P < 0.01). Overall, use of antibiotics for acute otitis media decreased from 93% to 87.4% (P < 0.05), and for upper respiratory tract infection, from 13.8% to 11.5% (P < 0.05). There were no significant changes in these factors for sinusitis. CONCLUSIONS: A targeted educational intervention can improve antibiotic prescription practices for respiratory infections in children and decrease unnecessary antibiotic use. Such studies can also pinpoint areas that require further attention.

Adolescent↗
PubMed2003

Comparison of the incidence rates of selected gastrointestinal events reported for patients prescribed rofecoxib and meloxicam in general practice in England using prescription-event monitoring data.

BACKGROUND: and objectives. Non-steroidal anti-inflammatory drugs (NSAIDs) are associated with gastrointestinal (GI) toxicity. Rofecoxib and meloxicam are classified as cyclooxygenase (COX)-2 selective inhibitors. The Drug Safety Research Unit monitored the safety of these drugs immediately after their launch in England using the non-interventional observational cohort technique of prescription-event monitoring (PEM). Our objective was to investigate whether there is a clinically relevant difference in the incidence of reported symptomatic (acid/peptic) and complicated upper GI conditions (perforations/bleeding) between rofecoxib and meloxicam during use in general practice. METHODS: Patients were identified from dispensed prescriptions written by general practitioners (GPs) for meloxicam (between December 1996 and March 1997) and rofecoxib (between July and November 1999). Simple questionnaires requesting details of events occurring during/after treatment and potential risk factors (including age, sex, history of upper GI problems, and NSAIDS prescribed within 3 months of treatment) were posted to prescribing GPs approximately 9 months after the first prescription for each patient. Incidence rates of the first event were calculated, and crude and adjusted rate ratios were obtained using regression modelling. RESULTS: For rofecoxib and meloxicam respectively, 1127 (7.4%) and 1376 (7.2%) patients had symptomatic (acid/peptic) upper GI events, whereas 57 (0.4%) and 67 (0.4%) had complicated upper GI conditions (perforations/bleeding). A past medical history of upper GI problems was an important risk factor only for symptomatic (acid/peptic) upper GI events for both drugs, despite a two-fold difference in the proportion reporting previous GI problems (48.4 and 25.1% for rofecoxib and meloxicam respectively). The adjusted rate ratio of symptomatic (acid/peptic) upper GI events or complicated upper GI conditions (perforations/bleeding) for rofecoxib compared with meloxicam was 0.71 (95% confidence interval 0.65, 0.79) and 0.91 (95% confidence interval 0.59, 1.42) respectively. CONCLUSIONS: This study reports a relative reduction (29%) in the incidence rate of symptomatic (acid/peptic) GI events, and no difference in the incidence rate of complicated upper GI conditions (perforations/bleeding) for rofecoxib compared with meloxicam.

Adult↗
PubMed1997

Prescription opiate abuse in chronic pain patients: clinical criteria, incidence, and predictors.

OBJECTIVES: Opiates are commonly used to treat patients with chronic nonmalignant pain. There is much controversy over the definition, incidence, and risk factors of prescription opiate abuse in chronic pain treatment. The present study, done at the Seattle VA Medical Center, was designed to create opiate abuse criteria, test inter-rater reliability of the criteria, apply the criteria to a group of chronic pain patients, and correlate the risk of opiate abuse with the results of alcohol and drug testing. DESIGN/OUTCOME MEASURES: A committee of experienced pain providers designed a five-point prescription opiate abuse checklist based on DSM-III-R parameters. The criteria were then applied to patients enrolled in the pain clinic. The reliability of the criteria were determined using two providers who were familiar with every patient in the clinic. Drug, alcohol, and psychosocial testing were correlated with the risk of opiate abuse. RESULTS: A total of 19% (76/403) of all pain clinic patients were using chronic opiates. Thirty-four percent (26/76) met one, and 27.6% (21/76) met three or more of the abuse criteria. The criteria had an inter-rater reliability of > 0.9. There were no differences between chronic opiate users (n = 76) and opiate abusers (n = 21) for a history of drug or alcohol abuse or on psychosocial testing. CONCLUSIONS: Prescription opiate abuse criteria for use in patients with chronic nonmalignant pain were designed. The criteria had good reliability and can be applied during normal clinic interactions. The percentage of chronic opiate users who become opiate abusers in pain treatment is within the range reported by others. Past opiate or alcohol abuse or psychosocial testing on clinic admission failed to predict who would become an opiate abuser. The criteria can be used to identify patients who will subsequently require more intensive treatment or intervention or can be used as an outcome to measure to test the effectiveness of treatment strategies.

Adult↗
PubMed1988

An experimental comparison of four hearing aid prescription methods.

Four hearing aid prescription methods were compared. A digital master hearing aid was used to produce the prescribed frequency gain characteristics. Measures of speech recognition and paired comparison judgments of relative speech intelligibility and speech quality were obtained at three output levels for each of the experimental frequency gain characteristics. No single prescriptive method emerged as being clearly superior. Relative performance of the four prescriptive methods varied as a function of output level. Similar results were observed for both speech recognition testing and paired comparison testing.

Adult↗
PubMed1998

Differences between prescription and consumption of antidepressants and anxiolytics.

The rate of detection of depressed patients by general practitioners (GPs) is generally reported to be lower than 50%, with some studies giving a value as low as 14%. In addition, GPs tend to overdiagnose anxiety and underdiagnose depression. Patients are not necessarily aware of the psychological nature of the disorder and only one-fifth list psychological complaints as the reason for contact. We collected information on the prescription and consumption of drugs in order to assess the influence of recognition of depression by GPs and of other factors on the treatment received by patients. Our results, which are particularly important in the context of current discussions on the cost of mental healthcare treatments, indicate not only a need for GPs to improve their identification rates but also a need to make patients more aware of the nature of their psychological diagnoses. When spontaneous psychological complaints are presented, the identification rate increases very substantially, and when patients are well aware of their conditions, compliance increases. It is clear from our results that greater specific recognition of psychiatric patients accompanied by the prescription of a specific treatment would not substantially alter the direct costs of drug prescription. On the contrary, it would very probably lower many costs, since the proportion of specific treatment given to properly identified patients is very low at present.

Adult↗
PubMed1981

Capitation payment for medicaid pharmacy services: impact on non-medicaid prescriptions.

Although pharmacy organizations have been instrumental in the movement to repeal antisubstitution laws, there is evidence that under the current fee-for-service system pharmacists have not exercised their newly obtained prerogatives freely. A previous study has demonstrated that paying pharmacists on a capitation basis for their Medicaid patients effects a highly significant increase in the rate of generic substitution. The present study was conducted to determine whether the pharmacists' newly acquired generic substitution habits "spill over" from Medicaid prescriptions as a result of capitation reimbursement. The results indicate that pharmacists who participated in the capitation experiment for the Medicaid drug program significantly increased their rate of generic substitution on non-Medicaid prescriptions. It was concluded that the same pharmacies that increased their substitution rate in the Medicaid program under capitation also increased their substitution rate on non-Medicaid prescriptions. Finally, generic substitutions in both the Medicaid and non-Medicaid studies generally involved the same labelers as well as drugs in the same therapeutic categories and with the same generic classifications.

Capitation Fee↗
PubMed1997

The effect of increased prescription drug cost-sharing on medical care utilization and expenses of elderly health maintenance organization members.

OBJECTIVES: The nature and extent of prescription drug benefits for the elderly are a continuing concern for health-care managers and policy makers. This study examined the impact of increased prescription drug cost-sharing on the drug and medical care utilization and expenses of the elderly. METHODS: Two groups of well-insured Medicare risk-based members of a large health maintenance organization (HMO) had their copayments increased in different years during a 3-year period. Four 2-year analysis periods were established for comparing these elderly groups. During one analysis period, copayments did not change in either group. RESULTS: Moderate increases of from $1 to $3, from $3 to $5 per copayment, and from 50% per dispensing to 70% per dispensing with a maximum payment per dispensing resulted in lower annual per capita prescription drug use and expenses. No consistent annual changes were observed in either medical care utilization (office visits, emergency room visits, home health-care visits, hospitalizations) or total medical care expenses across analysis periods. CONCLUSIONS: No consistent relationships were observed between increased copayments per dispensing and medical care utilization and expense. Future research needs to address the impact on the classes of medications received and related health status, and the impact of larger increases in copayments per dispensing on medical care and health-related factors.

Aged↗
PubMed2003

Physician and practice characteristics associated with the early utilization of new prescription drugs.

BACKGROUND: Prescription of new drugs contributes to substantial increases in annual drug expenditures. A small proportion of physicians appear to be early users of new prescription drugs and little is known about their characteristics. OBJECTIVE: To estimate the initial utilization rate of new prescription drugs among physicians, and the physician and practice characteristics associated with early use. DESIGN: Cumulative prospective assessment over a 5 year period (1989-1994) of new drug utilization rates in a randomly selected cohort of Quebec physicians. PARTICIPANTS: 1661 physicians and 669,867 elderly patients. OUTCOME: Prescribing rate of 20 new drugs, in 6 therapeutic categories, to elderly patients in the first 6 months after inclusion in the Quebec formulary. RESULTS: The 20 new drugs were prescribed by 1.3-22.3% of physicians, and there was an 8 to 17-fold difference in new drug utilization rates among prescribers. Characteristics associated with higher rates of utilization differed for general practitioners and specialists. Male general practitioners, and physicians graduating from the most recently established medical school in the province, had higher rates of new drug utilization, whereas recent graduation was only associated with higher utilization rates among specialists. Practice volume was associated with higher rates of utilization among GPs. For both GPs and specialists, having a high proportion of elderly in one's practice and a rural or remote practice location was associated with lower utilization rates. CONCLUSIONS: Physician sex, specialty, medical school, years since graduation, practice location, volume, and relative proportion of elderly in the physician's practice influence the utilization of new drugs.

Age Factors↗
PubMed1993

Effect of insurance status on pain medication prescriptions in a hematology/oncology practice.

To determine whether insurance status (payer class) affects the amount and type of pain medication prescribed, and whether patients in those groups without prescription drug coverage received lower-cost medications, a case-control study with retrospective chart review was initiated in a university-based hematology/oncology practice in northwest Louisiana. Charts of 710 active patients among all insurance groups (private insurance, Medicare, Medicaid, State Hospital System) were analyzed to determine insurance status, pain medication (amount and type), and diagnosis. The proportion of Medicaid patients receiving pain medications was significantly increased in relation to their representation in the practice when compared with Medicare patients, patients with private insurance, uninsured patients whose health care costs were provided by the State Hospital System, and the overall patient population. Medicaid patients, especially those with solid tumor malignancies, received the most expensive class of pain medications at a significantly higher rate than other patients. In the studied population of hematology and oncology patients, there is a significant difference in the amount and type of pain medications prescribed between patients with prescription drug coverage (Medicaid) and those without (all other groups including those covered by the statewide system). We propose that consideration be given to alternative methods of financing prescription medications for medically indigent patients.

Academic Medical Centers↗
PubMed2006

Economic impact of antiretroviral therapy prescription decisions in the context of rapid scaling-up of access to treatment: lessons from Mexico.

BACKGROUND: Mexico started scaling-up access to antiretroviral treatment in the late 1990s. Even though the Mexican Health System enrolled patients at impressive speed, in the initial years important aspects of the quality of care were overlooked. OBJECTIVE: To describe antiretroviral prescribing and adherence practices in Mexico during initial scaling-up of antiretroviral treatment in comparison to national treatment guidelines and to estimate the associated economic cost. METHODS: Eleven public sector hospitals provided detailed patient chart data. Monthly observations formed the basis of scenarios aligned by calendar month and by month before and after initiation of triple therapy. The scenarios varied by extent of prescription refill, adherence levels, and compliance with national treatment guidelines. RESULTS: Antiretroviral therapy prescription practices were largely inconsistent with published guidelines. Non-recommended combinations were prescribed to between 54 and 79% patients-months per year. Additionally, more than 50% of patients experienced four to 13 changes in treatment. Modeling of the economic impact of treatment practices showed that it would have been possible to effectively treat the same number of patients at the same or lower cost per patient. CONCLUSIONS: In addition to dispensing drugs, countries scaling-up antiretroviral therapy must find ways to ensure consistent drug supply, appropriate prescription practices and effective levels of adherence. Failing to do so will seriously reduce treatment effectiveness, greatly increasing the cost per unit of health benefit. With very low levels of effective adherence patients may even be harmed and the spread of multi-drug resistant virus facilitated.

Acquired Immunodeficiency Syndrome↗
PubMed2005

Booming prescription drug expenditure: a population-based analysis of age dynamics.

BACKGROUND: Prescription drug expenditures in North America have nearly doubled in the past 5 years, creating intense pressure for all public and private benefits managers and policymakers. OBJECTIVE: The objective of this study was to describe age-specific drug expenditure trends from 1996 to 2002 for the Canadian province of British Columbia. STUDY DESIGN: This study shows changes in expenditures per capita quantified for 5 age categories: residents aged 0 to 19, 20 to 44, 45 to 64, 65 to 84, and 85 and older. The cost impacts of 7 determinants of prescription drug expenditures are quantified. DATA: This study describes population-based, patient-specific pharmaceutical data showing the type, quantity, and cost of every prescription drug purchased by virtually all residents of British Columbia. RESULTS: Population-wide expenditures per capita grew at a rate of 11.6% per annum. Growth was primarily driven by the selection of more costly drugs per course of treatment and increases in the number concomitant treatments received per patient. Population aging did not have a major impact on expenditures. However, expenditure per capita grew most rapid among residents aged 45 to 64, the cohort that expended most over the period. The aging of this demographic cohort may threaten the financial viability of age-based drug benefit programs.

Adolescent↗
PubMed2006

Trends in prescription drug expenditures by Medicaid enrollees.

OBJECTIVE: As prescription drug expenditures consume an increasingly larger portion of Medicaid budgets, states are anxious to control drug costs without endangering enrollees' health. In this report, we analyzed recent trends in Medicaid prescription drug expenditures by therapeutic classes and subclasses. Identifying the fastest growing categories of drugs, where drugs are grouped into clinically relevant classes and subclasses, can help policymakers decide where to focus their cost containment efforts. METHODS: We used data from the Medical Expenditure Panel Survey linked to a prescription drug therapeutic classification system, to examine trends between 1996/1997 and 2001/2002 in utilization and expenditures for the noninstitutionalized Medicaid population. We separated aggregate trends into changes in population with use and changes in expenditures per user, and percent generic. We also highlighted differences within the Medicaid population, including children, adults, disabled, and elderly. RESULTS: We found rapid growth in expenditures for antidepressants, antipsychotics, antihyperlipidemics, antidiabetic agents, antihistamines, COX-2 inhibitors, and proton pump inhibitors and found evidence supporting the rapid take-up of new drugs. In some cases these increases are the result of increased expenditures per user and in other cases the overall growth also comes from an increase in the population with use. CONCLUSIONS: Medicaid programs may want to reassess their cost-containment policies in light of the rapid take-up of new drugs. Our analysis also identifies areas in which more information is needed on the comparative effectiveness of new versus existing treatments.

Adolescent↗
PubMed2006

PA attitudes toward prescription drug costs.

PURPOSE: This descriptive comparative study assessed PAs' knowledge of drug costs and attitudes about prescribing prescription medications. METHOD: Data were collected using a modified questionnaire. The survey instrument assessed PAs' attitudes about prescribing as well as their knowledge of prescription medication costs. RESULTS: Forty percent of the sample population were able to accurately identify the correct cost of medications. Most of the sample population considered costs when making a prescriptive decision. There were significant differences in the prescribing attitudes of PAs in various practice settings and medical specialties. CONCLUSIONS: The results of this study with PAs are similar to those of previous investigations involving physicians' knowledge of drug costs. We should recognize this deficit and ensure that a discussion of drug costs, particularly those associated with the Medicare population, is an important part of PA continuing education.

Attitude of Health Personnel↗
PubMed2006

A Jini-based solution for electronic prescriptions.

In most countries today, handwritten, paper-based medical prescriptions are the norm. While efforts have been made in the past and are being made at present to migrate toward electronic dispensation of prescriptions, these have generally omitted to incorporate ubiquitous computing technology in their proposed solutions. In this paper, we focus on this issue and describe a Jini-based prototypical solution for electronic prescriptions, which allows for their wireless transmission to in-range pharmacies and the augmentation of the service levels rendered to the user, with, for instance, information about queue lengths and estimated waiting times being provided to the patients. Clinical and user evaluation revealed that there were high levels of agreement as regards the prototype's effectiveness, ease of use, and usefulness.

Artificial Intelligence↗
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.↗