Knowledge of and barriers to health literacy in Illinois.

OBJECTIVE: To examine Illinois pharmacists' knowledge of and barriers to health literacy. DESIGN: Cross-sectional descriptive study. SETTING: Illinois, August to November 2009. PARTICIPANTS: 701 Illinois pharmacists. INTERVENTION: Mail survey. MAIN OUTCOME MEASURES: Pharmacists' knowledge (percent correct), mean barrier factors, and percent agreement of barrier items. RESULTS: Usable responses were obtained from 701 respondents out of 1,457 pharmacists receiving surveys (48.1%). Percent correct for knowledge items ranged from 31.5% to 95.4% with only 19% to 27% of respondents answering a majority of the items correctly. Pharmacists had poor knowledge (percent correct) about prevalence of low health literacy (31.5%), its relationship to years of schooling (46.9%) and its lack of relationship to reading comprehension (48.4%). Overall process and practice-related barrier domain items were the most important barriers. In particular, the most frequently cited barriers towards low health literacy interventions were lack of adequate time (90.4%), use of mail order (83.8%), and presence of convenient delivery mechanisms (82.8%), all process barriers. Majority of respondents (57.3%) agreed that lack of knowledge about health literacy and its consequences is a barrier. Significant differences existed for barrier factors by demographics. Multivariate analysis examining the relationship between knowledge and barriers after controlling for demographics revealed no significant differences. CONCLUSION: Pharmacists have limited knowledge of health literacy. We suggest training programs designed to address poor knowledge, interpreter services, access to written information tailored for various reading grade levels, and minimizing functional barriers such as time constraints.

Identifying aspects of pharmacists' attitudes and barriers toward health literacy: a factor analytic study.

BACKGROUND: Health literacy has gained prominence since the Institute of Medicine Report publicized the widespread prevalence of low health literacy. Pharmacists play an important role in enhancing health literacy as a result of their proximity to patients. Literature about pharmacists' perceptions and barriers in incorporating health literacy interventions is lacking. OBJECTIVE: To develop an instrument to measure pharmacists' attitudes and barriers toward health literacy. METHODS: A survey instrument assessing attitudes and barriers was designed based on a pharmacist focus group. The instrument was pretested among a sample of pharmacists from Illinois. The final instrument was administered to a systematic sample of 1500 pharmacists who were members of the Illinois Pharmacists Association. Dillman's 5-step total design method was followed to maximize survey responses. Exploratory principal components analysis with varimax rotation was performed on attitudes and barriers items to identify underlying components. Internal consistency of the components was determined using the Cronbach α and corrected item-total correlations. RESULTS: Overall, usable responses were received from 701 respondents, yielding a 48.1% response rate. Exploratory principal components analysis of the attitudes subscale produced a 5-factor solution that explained 55.87% of the variance. The 5 components included (1) low health literacy (LHL) situations, (2) LHL reasons, (3) LHL patient characteristics, (4) medication-related factors, and (5) LHL patient-interaction factors. The barriers subscale produced 3 components: (1) practice-related barriers, (2) knowledge and interaction-related barriers, and (3) process barriers, all of which explained 53.74% of the variance. Cronbach α values for the 5 attitudes subscales ranged from 0.33 to 0.78 and, for the 3 barriers, subscale values ranged from 0.56 to 0.71, offering evidence of internal consistency. CONCLUSIONS: Identification of components of pharmacists' attitudes and barriers toward health literacy will be useful to managers interested in incorporating health literacy interventions in their practice.

Psychometric properties of the Purdue Pharmacist Directive Guidance (PPDG) Scale in a sample of diabetes patients in the Southwestern United States.

Despite the fairly widespread adoption of the 10-item Purdue Pharmacist Directive Guidance Scale (PPDG) over the last decade, only one study has assessed its psychometric properties. The present study examined the validity and reliability of the scale in a sample of 99 diabetic patients in the Southwestern United States. Principal axis factor analysis with Varimax rotation yielded two factors, "Instruction" and "Feedback and Goal Setting," similar to those found when the scale was originally developed. Cronbach's alphas for the total scale and the two factors were 0.95, 0.95, and 0.92, respectively. The scale and the two factors correlated significantly and positively with number of visits by patients to the pharmacist in the past 3 mo. These results provide further evidence for the internal consistency, and construct and criterion-related validities of the scale.

Split-half and parallel reliabilities of the Purdue Pharmacist Directive Guidance Scale.

Using R and SPSS, various forms of split-half and parallel reliabilities were calculated. Robust split-half and parallel reliability coefficients for the Purdue Pharmacist Directive Guidance Scale are presented with coefficients greater than .84.

Mental Health Literacy of Pharmacy Students Compared to Nursing and Medical Students.

OBJECTIVES: To determine and compare the mental health literacy of pharmacy, nursing, and medical students. METHODS: Pharmacy, nursing, and medical students in the final year of their didactic program were administered a widely used mental health literacy questionnaire either via paper (nursing) or via email (pharmacy and medicine). For email questionnaires, weekly reminder emails with links for survey completion were sent over a three-week period. The questionnaire consisted of a vignette describing either depression or schizophrenia followed by items about helpfulness of a variety of interventions, medications, and activities. Depression and schizophrenia versions of the questionnaire were randomly administered to respondents in the three programs such that respondents received either male (John) or female (Jane) versions of the vignettes. RESULTS: A total of 161 out of 253 potential students responded to the survey (63.6% response rate). Majority of the respondents were female (75%), white (84.6%), had currently or in the past year interacted with people diagnosed with mental disorders (90%), and had multiple opportunities for exposure to mental health content in their coursework (49%). While a majority of respondents in all three programs correctly identified the vignettes as either depression (87%) or schizophrenia (73%), depression was identified correctly by a greater percent of those in pharmacy (88.5%) and nursing (88.4%), and schizophrenia was identified by a greater percent in medicine (82%). However, there were no significant differences by program type for correct identification of vignette. Helpfulness of various interventions, medications, and activities did not differ significantly for the depression vignette. Two significant differences by program type were noted for the schizophrenia vignette. A larger percent (72%) of nursing students perceived antidepressants as helpful for schizophrenia as compared to pharmacy (55%) and medical (18%) students. Students from all three programs responded similarly to the question on likely prognosis for those with depression/schizophrenia, both with and without professional help (p>0.01). CONCLUSIONS: Majority of students in each discipline were able to correctly identify patients with depression or schizophrenia and have similar levels of mental health literacy. The profile of responses suggest that pharmacy and nursing students were more clear about helpfulness of interventions for depression, than for schizophrenia. Given the extent of the problem of mental health, additional and continuously reinforced training on mental health throughout the four-year curriculum is necessary for first line providers such as pharmacists, nurses, and physicians.

Depressive symptoms in patients with type 2 diabetes in the ambulatory care setting: opportunities to improve outcomes in the course of routine care.

OBJECTIVES: To assess the frequency of untreated, self-reported depressive symptoms in a cross section of adult ambulatory patients with type 2 diabetes and to identify demographic and/or clinical characteristics associated with depressive symptoms in study patients. DESIGN: Cross-sectional study. SETTING: Three ambulatory care clinics in the southwestern United States in fall 2005. PATIENTS: 217 primary care patients aged 18 years or older with a diagnosis of type 2 diabetes. INTERVENTION: Administration of the Zung Self-rating Depression Scale (Zung SDS). MAIN OUTCOMES MEASURES: Self-reported data on demographic characteristics and depressive symptoms. Data for insurance, comorbid conditions, and glycosylated hemoglobin (A1C) values were abstracted from patient charts. RESULTS: Depressive symptoms (Zung SDS score > or =50) were identified in 72.1% of patients. Overall, 13% of the patients with a diagnosis of depression (based on patient charts) were not receiving treatment. Factors significantly associated with depressive symptoms were past history of depression (beta= 0.53, P < 0.01), Medicaid insurance (beta= 0.15, P < 0.02), and insulin use (beta= 0.12, P < 0.05). CONCLUSION: The results suggest that possible undetected or untreated depression can be assessed in patients with type 2 diabetes through use of a self-rating scale in the course of routine ambulatory care. Adding the Zung SDS screen to routine care protocols could facilitate improved detection and treatment of comorbid depression in ambulatory patients with type 2 diabetes.

The cost-effectiveness of two strategies for vaccinating US veterans with hepatitis C virus infection against hepatitis A and hepatitis B viruses.

OBJECTIVES: Although hepatitis A and B vaccinations are recommended for patients with chronic hepatitis C virus (HCV), the ideal vaccination strategy has not been determined. Our objective was to model the cost-effectiveness of two strategies for vaccinating patients with HCV infection against hepatitis A (HAV) and hepatitis B (HBV) viruses. The strategies evaluated were: universal vaccination with the combined HAV and HBV vaccine, and selective vaccination based on immunity determined by blood testing. METHODS: A decision tree model was constructed to compare the cost-effectiveness of the two vaccination strategies from the New Mexico Veterans Affairs Health Care System (NMVAHCS) perspective. A retrospective review of all HCV patients (2517 subjects) at the NMVAHCS was performed to extract prevalence of immunity to HAV and HBV, and prevalence of decompensated liver disease. Literature review was performed to obtain other probabilities for the model. Only direct medical costs were considered; the effectiveness measure was the number of patients immune to both HAV and HBV. Sensitivity analyses were performed to test robustness of the results to changes in input variables. All costs were in 2004 US dollars. RESULTS: The selective strategy was less costly but less effective, with a cost-effectiveness ratio of 105 dollars per patient immune to HAV and HBV. The universal strategy was more effective but more expensive with a cost-effectiveness ratio of 112 dollars per patient immune to HAV and HBV. Compared with the selective strategy, universal strategy was associated with an incremental cost-effectiveness (ICE) ratio of 154 dollars per additional patient immune to HAV and HBV. The universal strategy would become more cost-effective if 1) the cost of combined vaccine was reduced to less than 30.75 dollars (9.7% reduction), 2) the cost of HBV vaccine increased to greater than 34.50 dollars (25% increase), 3) the cost of blood tests for immunity increased to more than 25.25 dollars (23% increase), or (4) the prevalence of anti-HBs decreased to less than 24%. CONCLUSIONS: The selective vaccination strategy for HAV and HBV in our sample of patients with HCV is more cost-effective. However, the universal strategy is more effective and its ICE is minimal, thus it may be worth the additional cost.

Relationships between Hispanic ethnicity and attitudes and beliefs toward herbal medicine use among older adults.

BACKGROUND: Little is known about the underlying intentions to use herbal medicines among Hispanic older adults. Understanding these intentions is critical to the provision of effective counseling. OBJECTIVES: The objectives were to (1) identify predictors of the intention to use herbal medicines for health problems in the next 6 months among Hispanic and non-Hispanic older adults using the Theory of Planned Behavior (TPB); and (2) compare their beliefs underlying significant predictors of intention with use herbal medicines for health problems in the next 6 months. METHODS: Using a cross-sectional research design, data were collected via self-administered questionnaires from convenience samples at a Senior Health Clinic and a Veterans Affairs Hospital outpatient pharmacy. Study subjects were community dwelling adults aged 65 years and older and able to complete the survey in English. Multiple regression analysis was used to identify the significant predictors of intention to use herbal medicines in the TPB within each ethnicity. Independent t tests were used to compare the beliefs underlying the significant predictors of intention with use herbal medicines across the 2 groups. RESULTS: For both Hispanic (N=80) and non-Hispanic (N=171) patients, attitudes toward using herbal medicines was the only significant predictor of the intention to use herbal medicines in the next 6 months (Hispanics, Adj. R(2)=0.59, beta=0.78, P<.001; non-Hispanics, Adj. R(2)=0.57, beta=0.66, P<.001). The magnitude of the beta coefficients did not differ significantly between the 2 ethnicities. Compared with non-Hispanics, Hispanics believed that herbal medicines are cheaper, have fewer side effects, work better, and are more convenient to use than other medicines. CONCLUSIONS: Understanding ethnic differences in behavioral beliefs underlying attitudes toward the use of herbal medicines can help pharmacists and other health care professionals in educating and formulating appropriate counseling strategies specific to older patients of different ethnicities.

Economic, clinical, and humanistic outcomes (ECHOs) of pharmaceutical care services for minority patients: a literature review.

BACKGROUND: The U.S. population of racial/ethnic minorities continues to increase; however, health disparities and poor health outcomes among many of them continue to be a major public health problem confronting the U.S. health care system. OBJECTIVES: The objective of this review was to summarize published pharmaceutical care services literature reporting economic, clinical, and/or humanistic outcomes (ECHOs) among racial/ethnic minorities. Studies that reported differences by race/ethnicity and studies where most participants were from multiracial/ethnic minorities were included. METHODS: PubMed and International Pharmaceutical Abstracts databases were searched for articles that reported the effects of pharmaceutical care on ECHOs among racial/ethnic minorities published between January 1980 and November 2010. The literature review was focused on racial groups that included black/African-American, Native American, Indian American Asian, Alaska Native, Native Hawaiian, and Pacific Islander patients, and ethnic group that was non-white Hispanic/Latino patients. RESULTS: There were 24 articles that studied the impact of pharmaceutical care on ECHOs by race/ethnicity or where most participants were from multiracial/ethnic minorities. Twenty-three studies reported that pharmaceutical care has a positive impact on health outcomes of the studied populations. About half of the studies meeting inclusion criteria evaluated only 1 type of patient outcome, primarily clinical outcomes. Education/consultation and medication/therapy management were the most commonly evaluated types of pharmaceutical care services throughout the studied groups. Comprehensive disease management was evaluated mainly in multiracial/ethnic populations and blacks/African-Americans. Few studies adopted randomized controlled designs, which make it difficult to attribute changes in patient outcomes to the provision of pharmaceutical care. Nine studies that involved cooperation between pharmacists and other medical professionals reflect an increased tendency for interprofessional collaboration in the current health care system. CONCLUSION: This review shows that there is a positive relationship between pharmaceutical care and ECHOs in patients from racial/ethnic minority groups. However, more studies are needed to document the effects of pharmaceutical care on reducing racial/ethnic health disparities and to determine which interventions are most effective among certain groups with health disparities.

An evaluation of the psychometric properties of the Purdue Pharmacist Directive Guidance Scale using SPSS and R software packages.

BACKGROUND: The Purdue Pharmacist Directive Guidance (PPDG) Scale was developed to assess patients' perceptions of the level of pharmacist-provided (1) instruction and (2) feedback and goal-setting-2 aspects of pharmaceutical care. Calculations of its psychometric properties stemming from SPSS and R were similar, but distinct differences were apparent. OBJECTIVE: Using SPSS and R software packages, researchers aimed to examine the construct validity of the PPDG using a higher order factoring procedure; in tandem, McDonald's omega and Cronbach's alpha were calculated as means of reliability analyses. METHODS: Ninety-nine patients with either type I or type II diabetes, aged 18 years or older, able to read and write English, and who could provide written-informed consent participated in the study. Data were collected in 8 community pharmacies in New Mexico. Using R, (1) a principal axis factor analysis with promax (oblique) rotation was conducted, (2) a Schmid-Leiman transformation was attained, and (3) McDonald's omega and Cronbach's alpha were computed. Using SPSS, subscale findings were validated by conducting a principal axis factor analysis with promax rotation; strict parallels and Cronbach's alpha reliabilities were calculated. RESULTS: McDonald's omega and Cronbach's alpha were robust, with coefficients greater than 0.90; principal axis factor analysis with promax rotation revealed construct similarities with an overall general factor emerging from R. CONCLUSIONS: Further subjecting the PPDG to rigorous psychometric testing revealed stronger quantitative support of the overall general factor of directive guidance and subscales of instruction and feedback and goal-setting.

Depressive symptoms in patients with type 2 diabetes mellitus: do stress and coping matter?

This article examines the relationship among diabetes-related stress, appraisal, coping and depressive symptoms in patients with type 2 diabetes mellitus (T2DM) using the transactional model of stress and coping (TMSC) as the theoretical framework. In this cross-sectional study, a convenience sample of 201 patients with T2DM was recruited from three outpatient clinics. Patients with depressive symptoms reported significantly more diabetes-related stress than patients without depressive symptoms. The results of path analysis suggest that patients who experience greater diabetes-related stress or greater depressive symptoms have a negative appraisal of their diabetes. Negative appraisal is, in turn, associated with greater use of avoidance, passive resignation and diabetes integration coping and lesser use of problem-focused coping. Avoidance, passive resignation and diabetes integration coping are, in turn, related to greater depressive symptoms or greater diabetes-related stress. Overall, the results of this study support the TMSC as a framework to elucidate the relationships among diabetes-related stress, appraisal, coping and depressive symptoms in patients with T2DM. However, given the cross-sectional nature of the study, we are unable to elucidate the directionality of the relationship between stress and depressive symptoms. Implications of the findings and the need for longitudinal studies to evaluate these relationships are discussed.

Assessment of pharmacy student professionalism across a curriculum.

OBJECTIVES: To evaluate changes in professionalism across the curriculum among pharmacy students in different classes. METHODS: A professionalism instrument was administered early in the first (P1) year, upon completing the introductory pharmacy practice experiences (IPPE) near the end of the second (P2) year, and upon completing the advanced pharmacy practice experiences (APPE) at the end of the fourth (P4) year. RESULTS: The professionalism scale and its subscales were compared for the 3 time points for the class of 2009. Significant differences were noted in professionalism scores between the P1 and P4 years and for altruism, accountability, and honor/integrity subscale scores for the class of 2009. No significant differences were noted when the scores for 4 P1 classes, and 3 P2 classes were compared. CONCLUSION: An increase in professionalism scores and altruism, accountability, and honor/integrity scores was demonstrated, providing evidence that the curricular and co-curricular activities in the school of pharmacy helped develop professionalism in the class of 2009 students.

Active-learning strategies to develop health literacy knowledge and skills.

OBJECTIVE: To implement active-learning exercises in a required pharmacy course and assess their impact on students' knowledge and confidence in identifying and communicating with patients with low health literacy, as part of a required course in cultural competency, health literacy, and health beliefs. DESIGN: Active-learning activities including administering health literacy assessments, identifying informal signs of low health literacy, conducting mock patient counseling sessions, rating the readability of drug information, analyzing information in drug advertisements, and writing patient education materials were incorporated into the 6-sesssion health literacy portion of the course. ASSESSMENT: A pretest and posttest showed that students' knowledge of health literacy increased, and a retrospective pretest found improvement in students' confidence in their ability to care for patients with low health literacy. In-class discussions provided informal evidence that students gained new knowledge from the active-learning activities. CONCLUSION: The addition of active-learning activities was effective in teaching health literacy concepts to pharmacy students.

A cultural competency course for pharmacy students.

OBJECTIVE: To design, implement, and evaluate a course on health promotion and literacy. DESIGN: Course objectives such as the development of cultural competency skills, awareness of personal biases, and appreciation of differences in health beliefs among sociocultural groups were addressed using a team-based learning instructional strategy. Student learning outcomes were enhanced using readiness assessment tests (RATs), group presentations, portfolio reflections, and panel discussions. ASSESSMENT: Comparing precourse and postcourse Inventory for Assessing the Process of Cultural Competence among Healthcare Professionals (IAPCC-R) scores and portfolio responses indicated enhanced progress toward cultural competency. The Student Evaluation of Teaching (SET) provided suggestions for course enhancements. CONCLUSIONS: Evidence supporting enhanced cultural competency after completing the course affirms its value as we prepare pharmacy students to provide patient-centered care in a culturally diverse world.

Variables impacting an academic pharmacy career choice.

OBJECTIVES: To identify the variables associated with an academic pharmacy career choice among the following groups: final professional-year doctor of pharmacy (PharmD) students, pharmacy residents, pharmacy faculty members within the first 5 years of academic employment, and clinical pharmacy practitioners. METHODS: A cross-sectional design Web-based survey instrument was developed using the online tool SurveyMonkey. The survey link was distributed via e-mail and postcards, and data were collected anonymously. Quantitative analyses were used to describe the 2,494 survey respondents and compare their responses to 25 variables associated with an academic pharmacy career choice. Logistic regression models were used to predict the motivators/deterrents associated with an academic pharmacy career choice for each participant group. RESULTS: Across all participant groups, the potential need to generate one's salary was the primary deterrent and autonomy, flexibility, and the ability to shape the future of the profession were the primary motivators. Final-year pharmacy students who considered a career in academic pharmacy were significantly deterred by grant writing. The overall sample of participants who considered an academic pharmacy career was more likely to be motivated by the academic environment and opportunities to teach, conduct professional writing and reviews, and participate in course design and/or assessment. CONCLUSIONS: This study demonstrates specific areas to consider for improved recruitment and retention of pharmacy faculty. For example, providing experiences related to pharmacy academia, such as allowing student participation in teaching and research, may stimulate those individuals' interest in pursuing an academic pharmacy career.

A student orientation program to build a community of learners.

OBJECTIVES: To describe and evaluate a new student orientation program designed to lay the foundations for a community of learners. DESIGN: A weeklong orientation program structured as the first week of an 18-week fall semester was held for the first-professional year class. Each of the activities supported program objectives and developed elements of a community of learners. ASSESSMENT: Students' reflective portfolios, daily evaluations and final program evaluations provided evidence of development of a community of learners. Positive student observations included the use of technology, a discussion of the curriculum and experiential education, the use of reflective portfolios, and presentations from pharmacy practitioners. Students also appreciated becoming acquainted with the faculty, staff, and their peers in a non-threatening atmosphere. Some of the aspects rated as least helpful were the learning styles exercise, library tour, history of pharmacy session, and the overall length of the orientation. SUMMARY: A model for a new student orientation program that builds the foundations for the development of a community of learning, which is vital to preparing students to provide pharmaceutical care in interdisciplinary teams and become critical thinkers, was successfully established. This model could be implemented at other schools of pharmacy.

Pharmacy students' knowledge, attitudes, and evaluation of direct-to-consumer advertising.

OBJECTIVES: To assess pharmacy students' knowledge, attitudes, and evaluation of direct-to-consumer advertising (DTCA). METHODS: A cross sectional, self-administered, 106-item survey instrument was used to assess first, second, and third professional year pharmacy students' knowledge about DTCA regulations, attitudes toward DTCA, and evaluation of DTC advertisements with different brief summary formats (professional labeling and patient labeling) and in different media sources (print and television). RESULTS: One hundred twenty (51.3%) of the 234 students enrolled participated in the study. The mean percentage knowledge score was 48.7% +/- 12.5%. Based on the mean scores per item, pharmacy students had an overall negative attitude toward DTC advertisements. Students had an overall negative attitude toward television and print advertisements using the professional labeling format but an overall positive attitude toward the print advertisement using the patient labeling format. CONCLUSIONS: Lectures discussing DTC advertising should be included in the pharmacy curriculum.

Impact of pharmacists' directive guidance behaviors on patient satisfaction.

OBJECTIVE: To determine the impact of directive guidance (DG) behaviors by pharmacists on patient satisfaction with pharmaceutical care services. DG behaviors are social support behaviors and include such activities as supplying information about medications and providing encouragement and feedback regarding drug therapy. DESIGN: Cross-sectional observational study using a self-administered survey. SETTING: Two university-affiliated ambulatory care clinics, two chain pharmacies, and one independent pharmacy. PATIENTS: One hundred sixty patients with a chronic disease (e.g., asthma, hypertension, diabetes). MAIN OUTCOME MEASURE: Patient satisfaction with pharmaceutical care services. RESULTS: A total of 160 completed questionnaires were collected from patients at 5 sites. Overall, patients patronizing ambulatory care clinics perceived higher rates of DG behaviors and were more satisfied with pharmaceutical care services, compared with patients in community pharmacies (P < .05). The hierarchical regression model was significant (F(13,112) = 4.9091, P < .001). DG behaviors explained 32.4% (P < .001) of the variance in patient satisfaction with pharmaceutical care services. CONCLUSION: Higher rates of DG behaviors by pharmacists are associated with greater patient satisfaction with pharmaceutical care services.

Direct health care costs of 4 common skin ulcers in New Mexico Medicaid fee-for-service patients.

OBJECTIVE: To determine health care costs associated with pressure ulcers, ulcers of the lower limbs, other chronic ulcers, and venous leg ulcers from the New Mexico Medicaid fee-for-service program perspective. DESIGN: Retrospective analysis of claims database MAIN OUTCOME MEASURES: Physician visit, hospital, and prescription costs were determined for New Mexico Medicaid patients with a primary and/or secondary diagnosis of 1 of 4 identified categories of skin ulcers from January 1, 1994, through December 31, 1998. Costs were determined in terms of mean and median annual cost per patient and total costs per year. Zero dollar claims were included within the cost calculations. All costs are expressed in 2000-dollar values. MAIN RESULTS: Mean annual physician visit costs per patient ranged from $71 (standard deviation [SD] = $60) for venous leg ulcers in 1998 to $520 (SD = $1228) for pressure ulcers in 1996. Mean annual hospital costs per patient ranged from $266 (SD = $348) for other chronic ulcers in 1998 to $15,760 (SD = $30,706) for pressure ulcers in 1998. Mean annual prescription costs per patient ranged from $145 (SD = $282) for other chronic ulcers in 1998 to $654 (SD = $1488) for pressure ulcers in 1994. CONCLUSION: The New Mexico Medicaid fee-for-service system incurred a total cost of approximately $11.6 million (in 2000 dollars) from 1994 through 1998 for the treatment of the 4 categories of skin ulcers studied. The data showed that the majority of wounds were coded as pressure ulcers, which had the highest associated costs.