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PubMed2005

Toxicology screening in orthopedic trauma patients predicting duration of prescription opioid use.

Following hospitalization for orthopedic trauma, some patients continue to use opioids following fracture healing. This retrospective cohort study of 50 patients with high-energy fractures was conducted to determine if toxicology screening tests upon admission can predict subsequent opioid use. Data were collected from clinical records and a statewide electronic database of prescription records. Six months following hospital discharge, those with positive toxicology used more Following hospitalization for orthopedic trauma, some patients continue to use opioids following fracture healing. This retrospective cohort study of 50 patients with high-energy fractures was conducted to determine if toxicology screening tests upon admission can predict subsequent opioid use. Data were collected from clinical records and a statewide electronic database of prescription records. Six months following hospital discharge, those with positive toxicology used more. Following hospitalization for orthopedic trauma, some patients continue to use opioids following fracture healing. This retrospective cohort study of 50 patients with high-energy fractures was conducted to determine if toxicology screening tests upon admission can predict subsequent opioid use. Data were collected from clinical records and a statewide electronic database of prescription records. Six months following hospital discharge, those with positive toxicology used more opioids (730 mg vs. 364 mg; P = .04) expressed as morphine equivalents than those with negative toxicology and were more likely to continue using opiates at the end of the 3rd, 4th, 5th, and 6th month after discharge. Patients hospitalized for high-energy fractures with positive admission toxicology are at risk for prolonged opiate use during the initial six months following discharge.

Adult↗
PubMedDate not supplied

Iowa medicare beneficiaries' satisfaction and experiences with a prescription drug discount card and preferred drug list.

OBJECTIVE: To evaluate the expectations, experiences, and satisfaction with the Iowa Priority Prescription Savings (IPPS) program. DESIGN: Longitudinal descriptive study. SETTING: Iowa. PARTICIPANTS: Randomly selected Iowa Medicare beneficiaries who self-enrolled in the IPPS prescription discount card program. INTERVENTIONS: Three self-administered surveys mailed in November 2002, June 2003, and September 2004, during the first, second, and third years of IPPS operation. MAIN OUTCOME MEASURES: Expectations of drug discounts, amount of discounts received, awareness of the IPPS preferred drug list (PDL), and satisfaction with the program. RESULTS: Usable response rates for the three surveys were 43.5%, 31.0%, and 38.4%. About one fourth of members initially expected discounts of more than 20% on their prescription medications. After IPPS was implemented, many members were unaware of the discounts they were receiving, but the percentage of members reporting discounts of more than $20 per month increased from 7.4% in year 1 to 16.4% in year 3. More than one half of the members were unaware of which drugs were on the PDL in years 1 and 2, but this improved to 21% unawareness in year 3. Satisfaction with the program was low but improved over time. Members who received discounts, did not expect large discounts, or received a medication review were more satisfied with the program. CONCLUSION: Some IPPS members had unrealistic expectations about the amount of discounts they would receive, and expectations of large discounts decreased satisfaction. Satisfaction and amount of discounts improved over time, and beneficiaries whose medications were reviewed, usually by a pharmacist, were more satisfied with the program. PDL awareness was a problem despite substantial educational efforts by IPPS, a finding that has implications for the recently implemented Medicare Part D drug benefit.

Aged↗
PubMed2006

Physicians' perceived knowledge of and responsibility for managing patients' out-of-pocket costs for prescription drugs.

BACKGROUND: Most insurers in the US have implemented incentive-based formularies that rely on out-of-pocket costs to influence prescription drug utilization. Medicare Part D plans have broadly adopted such benefit designs. OBJECTIVE: To evaluate physicians' perceptions of their knowledge of formularies and out-of-pocket costs, factors that influence knowledge of costs, physicians' perceived responsibility for helping patients manage their out-of-pocket costs for prescription drugs, and physicians' perceptions of the role of pharmacists in managing these costs. METHODS: A multiple-choice survey was mailed to a random sample of 1200 physician members of the California Medical Association; a phone survey of nonresponders was then conducted. RESULTS: Of 1027 surveys delivered to correct addresses, 509 (49.6%) responses were received. Thirty-three percent of physicians reported that they were usually or always aware of patients' formularies and 20% were usually or always aware of patients' out-of-pocket costs for medications. Surgeons, emergency department physicians, and physicians that prescribe from more formularies than other physicians are less likely to be aware of patients' out-of-pocket costs, while physicians in large practices and those who use computers to prescribe are more aware. While 91% of physicians agreed that it is important that patients' out-of-pocket costs be managed, 40% somewhat or strongly agreed that it is their responsibility to help. Sixty-five percent of physicians believed that it is the responsibility of the pharmacist to be familiar with patients' out-of-pocket costs. CONCLUSIONS: Physicians often lack the knowledge to assist patients in the management of their out-of-pocket costs for prescription drugs and they depend on pharmacists to help patients manage those costs. Computer order entry and resources available in large physician organizations improve physicians' awareness of out-of-pocket costs when prescribing.

Attitude of Health Personnel↗
PubMedDate not supplied

Government commitment and regulation of prescription drugs.

Two papers in this volume review efforts worldwide to control the growth of drug spending and discuss the potential role for the U.S. government with respect to rationing of prescription drugs. I put the roles given to government in the two papers in context by focusing on the role of government as a partner with the pharmaceutical industry. I concentrate on the unique features of the prescription drug market, coupled with the fact that government is a payer, regulator, and provider in the health sector. I conclude that the federal government should exercise caution when attempting to regulate prescription drug prices.

Aged↗
PubMedDate not supplied

Financial disparities in prescription drug use between elderly and nonelderly Americans.

This study examines cross-sectional disparities in the financial burden of prescription drug use among U.S. elderly and nonelderly adult populations, using data from the 1998 Medical Expenditure Panel Survey. Out-of-pocket spending for prescriptions, copayment rates, and the proportion of family income spent on prescription drugs were examined to compare elderly people with working-age adults. Even after utilization or need was adjusted for, financial disparities were still observed between elderly and nonelderly adult populations. In particular, low-income elderly people were worse off than were nonelderly adults in the same poverty class and their elderly peers in other poverty classes.

Adolescent↗
PubMedDate not supplied

States' control of prescription drug spending: a heterogeneous approach.

In an effort to balance Medicaid budgets, states use prescription drug cost containment tools in unique ways and in varying combinations. We report on the variability in state-level strategies to control the cost of prescription drugs and describe broad state-to-state differences in per beneficiary spending on drugs. This heterogeneity raises the question of appropriate state program variability. Research is needed to determine the medically, ethically, and legally most suitable means of controlling drug costs, especially as the Medicare Part D drug plan will likely recapitulate the prescription drug program variability observed among the states.

Aged↗
PubMed2004

The effect of Roux-en-Y gastric bypass on prescription drug costs.

BACKGROUND: This study examines the effect of weight loss following laparoscopic Roux-en-Y gastric bypass (RYGBP) for morbid obesity on prescription drug costs in patients over the age of 54. METHODS: 78 patients aged 55 to 75 who met the inclusion criteria were identified in a database of 1,060 morbidly obese patients undergoing LRYGBP between March 2001 and March 2003. All prescription drugs and dosages were recorded preoperatively and postoperatively at 6 months, 1 year, and yearly thereafter. Drug history was obtained from the patient and verified by records from referring physicians' offices. The cost of a 30-day supply of each drug was obtained from 3 retail sources and averaged. RESULTS: The average pre-LRYGBP cost of prescription drugs was $368.65 per month per patient. The average annualized cost at 6 months after LRYGBP was $119.10 per month (down 68%), at 1 year $118.67 (down 68%) and at 2 years $104.68 per month (down 72%). CONCLUSIONS: Weight loss resulting from LRYGBP significantly reduces obesity-related morbidities, resulting in a substantial reduction in medication needs in patients over the age of 54. The projected cost savings realized in the 78 patients in this study amounts to approximately $240,566.04 annually.

Age Factors↗
PubMed2006

Proton pump inhibitor use and risk of community-acquired Clostridium difficile-associated disease defined by prescription for oral vancomycin therapy.

BACKGROUND: The association between the use of proton pump inhibitors and the risk of Clostridium difficile-associated disease (CDAD) is controversial. In this study we re-examined a previously reported association between the use of proton pump inhibitors and the development of community-acquired CDAD, this time using an alternative case definition of the disease. METHODS: We performed a case-control study of community-acquired CDAD using a United Kingdom clinical research database. Patients receiving oral vancomycin therapy were identified as having CDAD, the only indication for this drug. Each case subject was matched with up to 10 control subjects. Neither the cases nor the controls had been admitted to hospital in the year before the date of the vancomycin prescription (index date). Conditional logistic regression analysis was used to adjust for key covariates. RESULTS: We identified 317 cases of community-acquired CDAD treated with oral vancomycin therapy and 3167 matched control subjects. Exposure to a proton pump inhibitor in the 90 days before the index date was associated with an increased risk of CDAD (odds ratio [OR] 3.5, 95% confidence interval [CI] 2.3-5.2). Antibiotic exposure in the 90 days before the index date was also a significant risk factor for community-acquired CDAD (OR 8.2, 95% CI 6.1- 11.0), even though 45% of the case subjects had not received a prescription for an antibiotic during that period. Certain comorbidities, in particular renal failure, inflammatory bowel disease and malignant disease, as well as prior methicillin-resistant Staphylococcus aureus infection, were also associated with an increased risk. INTERPRETATION: Proton pump inhibitor use was associated with an increased risk of community-acquired CDAD, when cases were defined by receipt of prescription for oral vancomycin therapy. Prior antibiotic exposure was also a significant risk factor, but a significant proportion of the patients with community-acquired CDAD had no such exposure.

Aged↗
PubMed2006

Potential interactions between prescription drugs and complementary and alternative medicines among patients in the emergency department.

STUDY OBJECTIVE: To determine the nature and prevalence of potential interactions between prescription drugs and complementary and alternative medicines (CAMs) and the reasons some patients do not advise their physicians of CAM use. DESIGN: Cross-sectional survey. SETTING: The emergency department of the Royal Melbourne Hospital, a tertiary referral center. PATIENTS: Four hundred four adult patients (>or= 18 yrs) who visited the emergency department between February 1, 2002, and March 31, 2003. Intervention. A specifically designed, self-administered questionnaire, available in seven languages. MEASUREMENTS AND MAIN RESULTS: Main outcome measures were the prevalence of potential prescription drug-CAM interactions and the reasons some patients do not advise their physicians of CAM use. Mean +/- SD patient age was 50.6 +/- 20.0 years; 220 patients were men (54.5%, 95% confidence interval [CI] 49.5-59.4%). When asked about use during the previous year, 275 patients (68.1%, 95% CI 63.2-72.5%) reported having taken a CAM; of these, 138 were also taking a prescription drug. We identified 15 documented potential drug-CAM interactions in nine patients (3.3% of CAM users, 95% CI 1.6-6.3%) and 97 theoretical potential drug-CAM interactions in 51 patients (18.6% of CAM users, 95% CI 14.2-23.8%). Aspirin and warfarin were the most commonly involved drugs. Of CAM users, 197 (71.6%, 95% CI 65.9-76.8%) never informed their physician about CAM use, most frequently because they were not asked. CONCLUSION: The prevalence of potential drug-CAM interactions among patients in the emergency department is considerable, and some of these interactions could be clinically significant. Practitioners should increase their awareness of potential drug-CAM interactions, and education initiatives aimed at encouraging patient-physician discussion of CAM use are recommended, such as a CAM history in their patient evaluation. Further research is required to better determine the clinical significance of drug-CAM interactions.

Adult↗
PubMed2005

New prescription drug benefit: the role of the oncologist.

Increasingly, cancer drugs are being developed for oral self-administration, and those oral drugs are frequently among the most sought-after by oncologists and patients, as their targeted mechanisms offer the promise of greater effectiveness with fewer toxicities. It is quite timely, therefore, that the Medicare program on January 1, 2006, will launch a new prescription drug benefit to cover, for the first time, oral and other self-administered prescription drugs for cancer and other diseases. The new benefit, Part D, is clearly a positive development for cancer patients, but it introduces new complexity to the process of selecting and financing prescription drug coverage. Oncologists, like other physicians, should be prepared to advise their patients concerning options for coverage.

Antineoplastic Agents↗
PubMed2003

Racial and ethnic disparities in emergency department analgesic prescription.

OBJECTIVES: We examined racial and ethnic disparities in analgesic prescription among a national sample of emergency department patients. METHODS: We analyzed Black, Latino, and White patients in the 1997-1999 National Hospital Ambulatory Medical Care Surveys to compare prescription of any analgesics and opioid analgesics by race/ethnicity. RESULTS: For any analgesic, no association was found between race and prescription; opioids, however, were less likely to be prescribed to Blacks than to Whites with migraines and back pain, though race was not significant for patients with long bone fracture. Differences in opioid use between Latinos and Whites with the same conditions were less and nonsignificant. CONCLUSIONS: Physicians were less likely to prescribe opioids to Blacks; this disparity appears greatest for conditions with fewer objective findings (e.g., migraine).

Adolescent↗
PubMed2005

Medicare-approved drug discount cards and prescription drug prices.

PURPOSE: Prescription drug prices with and without the use of Medicare-approved drug discount card programs (MADDCs) to purchase medications were studied. METHODS: The Medicare.gov Web site was used to determine if the 200 most frequently prescribed drugs in the United States in 2003 were covered by a MADDC. The lowest and highest MADDC prices at local and mail-order pharmacies and the corresponding non-MADDC prices at the same community pharmacies or an Internet pharmacy, respectively, were determined. Wilcoxon signed rank tests were used to determine if there was a difference between non-MADDC medication prices and MADDC prices. RESULTS: Of the top 200 medications prescribed in 2003, 192 (96%) and 189 (94.5%) were covered by at least one MADDC in a local pharmacy or mail-order pharmacy, respectively. Overall, MADDCs saved money compared with purchasing medications without a MADDC (p < 0.001). However, a MADDC resulted in a higher price than the retail non-MADDC price for 61 (31.8%) of the prescription medications at local pharmacies, and using a MADDC at a mail-order pharmacy resulted in a higher price than the Internet pharmacy non-MADDC price for 143 (75.7%) of the drugs. CONCLUSION: MADDC prices for common prescription medications were generally lower than prices when MADDCs were not used. The highest mail-order MADDC prices were often higher than Internet non-MADDC prices.

Community Pharmacy Services↗
PubMed2006

Patient assistance programs and patient advocacy foundations: alternatives for obtaining prescription medications when insurance fails.

PURPOSE: The role of patient assistance programs and patient advocacy foundations as a safety net for Americans without health insurance or with inadequate insurance, the financial impact of 14 years of experience promoting enrollment in such programs at a cancer treatment center, and resources and strategies that pharmacists can use to increase patient enrollment and access to needed medications are discussed. SUMMARY: Various patient assistance programs and patient advocacy foundations offer financial and other support for patients who need help obtaining prescription medications because they lack health insurance or their insurance fails to meet their needs. Patients must complete an application and provide personal financial information. Efforts by a pharmacist at a cancer treatment center to enroll patients in such programs produced a marked reduction in write-offs over a 14-year period. Pharmacists can promote patient enrollment in assistance programs by screening for costly drugs and patients who are likely to have difficulty obtaining these drugs. These patients include those who exceed Medicaid coverage or for whom Medicaid coverage is pending, patients without any health insurance, patients without a prescription drug benefit, patients for whom the planned drug therapy is not covered by insurance, and patients enrolled in charity programs. CONCLUSION: Patient assistance programs and patient advocacy foundations provide a valuable safety net to ensure that Americans without health insurance or with inadequate coverage receive needed prescription medications.

Cancer Care Facilities↗
PubMed2006

Serious skin reactions and selective COX-2 inhibitors: a case series from prescription-event monitoring in England.

BACKGROUND: The erythema multiforme (EM) spectrum of bullous eruptions (toxic epidermal necrolysis [TEN] and Stevens-Johnson syndrome [SJS]) are rare and serious skin reactions that have been reported for cyclo-oxygenase (COX)-2 selective inhibitors. Our objectives were to identify and describe cases of serious skin reactions reported during postmarketing studies of COX-2 selective inhibitors. METHODS: A retrospective review of information from reports of serious skin reactions reported during prescription-event monitoring (PEM) studies of rofecoxib, celecoxib, etoricoxib and valdecoxib conducted in England since 1999. Exposure data were derived from dispensed prescriptions written by primary care physicians for each study drug. Outcome data were derived from questionnaires posted to prescribers at least 9 months after the date of the first prescription for each patient (valdecoxib data collection ongoing at the time of this study). Reports of EM, exfoliative dermatitis, SJS, TEN and symptoms associated with EM (EM syndrome) were identified from the PEM database. Additional data on diagnosis, relevant risk factors and management were requested for each case from the prescriber. A causality assessment was undertaken by a Drug Safety Research Unit research fellow and referred for expert review to a consultant dermatologist. RESULTS: Nine cases of serious skin reactions and two cases of symptoms associated with EM (EM syndrome) were identified. No reports of TEN were recorded. Six skin reaction questionnaires were returned. Of the nine cases of serious skin reactions, four cases (all SJS; one for each COX-2 selective inhibitor studied) were assessed as possibly related to use of the study drug (for combined cohorts: incidence risk 0.008%, 4 of 52,644 patients; rate 0.019 per 1000 patient-months of treatment). These four cases (two male, two female; age range 54-64 years) occurred within 2 weeks of starting treatment; the patient prescribed rofecoxib had reported risk factors (history of allergy, adverse reaction [asthma] to ibuprofen). The two cases from the EM syndrome search (one female, 35 years; one male, 80 years) occurred within 2 weeks of starting treatment; both were assessed as possibly related to use of celecoxib but considered suggestive of angio-oedema/urticaria and hypersensitivity reactions. CONCLUSIONS: This case series provides useful and complementary information to other published studies about serious skin reactions reported during treatment with COX-2 selective inhibitors. The crude incidence of cases of SJS possibly related to the use of a COX-2 selective inhibitor in this case series is very low (0.008% for all four cohorts combined). Prescribers and patients should be aware of the severe and life-threatening risk of EM potentially associated with NSAIDs, including COX-2 selective inhibitors.

Adult↗
PubMed2005

Adverse drug reactions in an elderly hospitalised population: inappropriate prescription is a leading cause.

OBJECTIVE: Adverse drug reactions (ADRs) represent a major public health problem in the aged. In order to better evaluate this problem in Brazil, this study was designed to assess the prevalence of ADRs in an elderly hospitalised population, identify the most common ADRs and the principal medications involved, evaluate the appropriateness of use of these drugs in elderly people and determine the risk factors implicated in the appearance of such ADRs. METHODS: The study population was comprised of 186 elderly patients (> or =60 years of age) admitted to the internal medicine service of a teaching hospital. The patients were assessed by a single observer using an intensive drug surveillance method to identify and report ADRs. The degree of probability for each adverse reaction was determined using the Naranjo algorithm. RESULTS: The mean (+/- SD) age of the patients studied was 73.6 +/- 9.1 years. Up to 115 patients (61.8%) of the study population presented at least one ADR. A total of 199 ADRs were found, at an average of 1.7 per patient. The ADRs appeared during hospitalisation in 46.2% of the study population, were present at the time of the admission but did not cause hospitalisation in 17.2% of patients, and were the cause of admission in 11.3% of patients. The most frequent ADR that caused hospitalisation was digitalis toxicity (22.7% of such ADRs). Hypokalaemia as a result of diuretics was the most prevalent ADR both during hospitalisation (11.8%) and at the time of admission without being the cause (12.1%). Captopril was the most frequently prescribed drug (138 prescriptions), and led to an ADR in 18.1% of patients who received the drug. Almost a quarter of the patients presenting an ADR were prescribed drugs considered inappropriate for the elderly. By means of a multiple logistic regression model, the following were considered to be significant risk factors for the appearance of ADRs: number of diagnoses (odds ratio [OR] 1.40; 95% CI 1.06, 1.86), number of drugs (OR 1.07; 95% CI 1.01, 1.13) and use of drug that is inappropriate for the elderly (OR 2.32; 95% CI 1.17, 4.59). DISCUSSION: The main contribution of the present study was identification of use of drugs that are considered inappropriate for elderly populations as a major risk factor for presenting an ADR. This finding is useful for continuous education programmes, therapeutic committees and policy makers, because adverse effects complicate the course of diseases in aged patients, cause hospitalisation and/or require the prescription of additional drugs. In addition to contributing to a reduction in healthcare costs, continuous efforts to promote rational drug use could also benefit elderly patients by preventing some avoidable drug toxicity. CONCLUSION: A significant prevalence of ADRs was found among hospitalised elderly people. The risk factors associated with ADRs in this population included use of drugs considered to be inappropriate for that population, number of previous diagnoses and number of administered drugs. More appropriate drug prescription could avoid part of this burden of disease by minimising preventable ADRs.

Adverse Drug Reaction Reporting Systems↗
PubMed1999

The effect of generic competition on prescription to over-the-counter switching.

OBJECTIVE: While it is generally accepted that the decision to switch a drug from the prescription market to the over-the-counter (OTC) market is based on an optimization problem that firms are solving, no attempts have been made to formalize the problem. The purpose of this article is to present a model of prescription to OTC switching that helps explain the role of potential generic competition in a firm's decision to switch. In particular, we examine what market conditions are necessary for the threat of generic competition to induce switching. DESIGN AND SETTING: The model is game-theoretic, played between an incumbent firm and a potential generic entrant, and is solved for its subgame perfect equilibrium. The incumbent first decides whether to apply to the FDA to switch to the OTC market. If the incumbent declines, then the potential generic entrant has the opportunity to apply for the switch. The FDA then accepts or rejects the application, and the generic chooses whether to enter the market. RESULTS: In equilibrium, when applying to switch is costless, switching occurs if the probability that the application will be approved by the FDA is strictly positive and the OTC market is characterized by first-mover advantages. Adding a cost to the application process places restrictions on the probability of FDA approval to offset the cost of applying. The probability of approval must be sufficiently high to offset the cost of the application. CONCLUSIONS: The model shows that switching from the prescription to OTC market may occur as a response to potential generic competition. Firms switch because they know that if they do not, a generic may initiate a switch and become the first mover in the OTC market.

Drug Costs↗
PubMed2005

[Current status of team communication considered from a questionnaire survey on the laboratory prescription card].

Team communication between dentists and dental technicians offers high-quality medical treatment for patients. When dentists and dental technicians understand dental treatments and laboratory procedures and talk to each other from an equal standpoint, good team communication between them can be established. However, undergraduate dental students do not sufficiently understand the content and processes of laboratory procedures because the subjects and hours in laboratory procedures have been reduced at present. Education on team communication between dentists and dental technicians is not sufficiently included in the training content of postgraduate training practice. It seems that at present, it is difficult for good team communication to be established between new graduate dentists and dental technicians. In view of this, the current status of the team communication between dentists and dental technicians in the present clinic was investigated, because a guideline for constructing team communications between dentists and dental technicians is given in the dental education before and after graduation. That is to say, the current status of the team communication of dentists and dental technicians was investigated by considering a questionnaire survey on the laboratory prescription card, which is the most important information means for connecting dentists with dental technicians in the dental clinic. The results were as follows: The entry items were insufficient on the laboratory prescription cards. Therefore, it is necessary to prepare such laboratory prescription cards that required items are entirely indicated as well as to enter them fully by dentists.

Communication↗
PubMed2006

The comfort level of internists with the prescription of psychotropic medication.

INTRODUCTION: Empirical data indicate that patients seen in internal medicine outpatient settings have substantial rates of depression and other psychiatric disorders. Surprisingly, the training requirements established by the Residency Review Committee in Internal Medicine do not include a specific psychiatry training curriculum, but rather vaguely refer to "sufficient instruction and clinical experience" in psychiatry. METHOD: In this study, internists on staff at a community hospital were surveyed to ascertain their general level of comfort with prescribing psychotropic medication. The study hypotheses were: (1) compared with other psychotropic medications, internists would generally be most comfortable with the prescription of antidepressants; (2) younger, rather than older, internists would be more comfortable with prescribing psychotropic medications; and (3) internists with greater outpatient, versus inpatient, responsibilities would be more comfortable with psychotropic medication prescription. RESULTS: This sample of internists demonstrated differences in prescribing comfort by medication group (F(3) = 48.99, p < .001) and was most comfortable in prescribing antidepressants and benzodiazepines, in contrast to antipsychotics and other types of psychotropic medications; comparing older with younger internists, there was a significant between-group difference in the mean number of medications positively endorsed, t(66) = 2.16, p <.05, with younger internists indicating broader comfort levels; and inpatient internists were significantly more comfortable prescribing antipsychotics than outpatient internists, t(117) = -3.38, p = .001. CONCLUSIONS: There are some distinct psychotropic prescription trends among internists, which have implications for future training and quality improvement programs.

Adult↗