Effects of Medicaid drug utilization review intervention letters.

The state of Texas Drug Utilization Review (DUR) Board, composed of six physicians and six pharmacists, meets quarterly to determine criteria for implementing retrospective DUR. The board agreed to send intervention letters to physicians concurrently prescribing: (1) two histamine2 (H2)-antagonists (H2As) or (2) either any H2A or omeprazole with sucralfate. To measure the effect of these intervention letters, approximately half of these physicians were randomly chosen to receive a letter while the others served as a control group and did not receive letters. This project focused on the H2A or omeprazole with sucralfate intervention letters in a two-step process. Data on concurrent therapy involving two H2As were analyzed separately and these results are not included in this report. Objective one was to examine feedback from the physicians who received the letters, and objective two was to review and compare patient profiles 6 months after the letters were sent. Analysis of Medicaid prescription claims indicated that 190 physicians had concurrently prescribed either an H2A or omeprazole with sucralfate for 222 patients. Ninety-seven physicians (from 117 identified patient profiles) were selected to receive an intervention letter with their patient's profile or profiles, a response form, and a stamped envelope addressed to the Texas Department of Human Services. A 67.5% response rate was obtained. Of these responses, 49.4% agreed with the letter and 29.1% disagreed with the letter. The remaining indicated responses such as "not my patient," they were no longer seeing the patient, or that they did not prescribe the medication in question. (ABSTRACT TRUNCATED AT 250 WORDS)

Meta-analyses of the effectiveness of erythropoietin for end-stage renal disease and cancer.

Anemia, a decreased oxygen-carrying capacity of the blood, develops frequently in patients with end-stage renal disease (ESRD) or cancer. Given the wide variation in clinical response to erythropoietin in the treatment of anemia associated with these diseases, 2 meta-analyses of its effectiveness were undertaken. Databases (MEDLINE and International Pharmaceutical Abstracts) were searched to identify relevant articles. Search terms included erythropoietin, anemia, end-stage renal disease, cancer, multiple myeloma, and myelodysplastic syndrome. Searches were limited to human subjects and the English language. Reference lists of identified articles were reviewed for further articles of interest. The primary author (W.A.M.) selected the articles, and 2 researchers, working independently, extracted the necessary data. Articles had to meet the following criteria to be included in the meta-analyses: (1) Articles must have dealt with treatment of subjects with documented anemia. (2) Studies must have been original research with sample size > or =10. (3) Abstracts could be included if the full research manuscript was unavailable. (4) Patients could not be concurrently receiving other growth factors. (5) The quality of the selected articles must have been assessed by 2 independent researchers. A clinical response to erythropoietin was defined as a 0.06 increase in hematocrit or a 20 g/L increase in hemoglobin. Thirty-nine of the 76 identified articles were included in the meta-analyses. The effectiveness of erythropoietin was calculated at 87% for ESRD, 79% for multiple myeloma, 40% for solid tumor cancer, and 13% for myelodysplastic syndrome. Both subgroup and sensitivity analyses were performed.

Dealing with skewed data: an example using asthma-related costs of medicaid clients.

BACKGROUND: Cost data often are nonnormally distributed due to a few very high cost values that may not necessarily be dismissed as outliers. Researchers have not reached agreement on how to appropriately deal with skewed cost data. OBJECTIVES: This study presents an example of skewed cost data that were collected retrospectively from the Texas Medicaid database. Common methods of dealing with skewed cost distributions are discussed. Data were analyzed using various methods, and the statistical results of each test were compared. METHODS: Prescription and medical claims data extracted from the Texas Medicaid database were analyzed using the Mann-Whitney U test and t tests of untransformed, log-transformed, and bootstrapped data. RESULTS: All distributions of the untransformed cost data were nonnormally distributed, and comparison groups had unequal variances. The Mann-Whitney U test negated the effect of the high-cost patients and gave a significant result for overall cost differences between groups, but in the opposite direction of the mean. The t tests on raw data and log-transformed data may not have been optimal because distributions of both raw costs and log-costs were nonnormal. CONCLUSIONS: The bootstrap method does not need to meet the assumptions of normality and equal variances. In analyses of small sample sizes with skewed cost data, the bootstrap method may offer an alternative to the more traditional nonparametric or log-transformation techniques.

Patterns of antihypertensive use among patients in the US Department of Defense database initially prescribed an angiotensin-converting enzyme inhibitor or calcium channel blocker.

The US Department of Defense recently assembled electronic records of outpatient prescriptions dispensed through the Uniformed Services Prescription Database Project (USPDP) going back to 1990. The objectives of this portion of a larger study were: (1) to examine longitudinally the patterns of antihypertensive drug use during the first year of therapy in patients whose initial therapy was with an angiotensin-converting enzyme (ACE) inhibitor or a calcium channel blocker (CCB); (2) to determine continuous and noncontinuous users of antihypertensive drugs; and (3) to estimate the direct medication costs for each pattern of medication use. Filtering criteria for patient and prescription identification were developed, because the USPDP contains no records of confirmatory diagnoses of hypertension. Once data filters were implemented, information for 771 patients was analyzed. An ACE inhibitor was the initial therapy for 328 patients, accounting for 1935 antihypertensive medication prescription fills, and a CCB was the initial therapy for 443 patients, accounting for 2459 fills (including refills). Slightly more than half of the patients (n = 401, 52.0%) were classified as continuous users (> or = 80% medication-possession ratio [supply of medication in days divided by the number of days in the 12-month study period]). In the first year, 177 of these continuous users (44.1%) had no change in therapy in the first year, 49 (12.2%) had an increase in dose, 8 (2.0%) had a decrease in dose, 15 (3.7%) had a change to a different therapeutic class of antihypertensive medication, 14 (3.5%) were changed to a different medication in the same therapeutic class, 20 (5.0%) had a new medication added to the regimen, and 118 (29.4%) had complex regimens involving more than one change. For continuous users, the mean medication supply in days was 354.6, and the average time before a medication change was 152.1 days for those continuous users who had one change in therapy. The overall average wholesale price (AWP) and average manufacturer price (AMP) for continuous users during 1 year of therapy were $471.31 and $378.51, respectively. For those patients whose therapy was changed to an ACE inhibitor/CCB combination and who were continuous users, the average AWP was $598.47 per year ($492.05 AMP). Once the change from monotherapy to an ACE inhibitor/CCB combination occurred in continuous users, AWP costs per member per month increased by approximately $22.00 ($18.00 AMP). Over half of the patients whose initial therapy was an ACE inhibitor or CCB had at least one change in their first year of therapy. Research into the reasons for these changes and their outcomes is needed.

Economic analysis of carboplatin versus cisplatin in lung and ovarian cancer.

OBJECTIVE: To conduct an economic analysis on the use of carboplatin versus cisplatin over multiple courses in patients with lung [nonsmall cell lung cancer (NSCLC) and small cell lung cancer (SCLC)] or ovarian cancer. DESIGN: This 1-year study was a prospective, multicentre, cost-minimisation evaluation. Direct medical resource utilisation and costs associated with carboplatin and cisplatin administration over 3 to 6 courses of treatment were measured and compared. The perspective of this evaluation was that of the payer. SETTING: A convenience sample of 16 sites representing a mix of cancer centres, outpatient clinics, medical centres and managed-care sites in a general practice oncology setting participated. PATIENTS AND INTERVENTIONS: Patients were included in this study if they were newly diagnosed with NSCLC, SCLC or ovarian cancer, had not received prior chemotherapy, received either carboplatin or cisplatin as their treatment (additional chemotherapy agents were allowed), and received at least 3 courses of carboplatin or cisplatin therapy up to a maximum of 6 courses. Patients receiving more than 6 courses of therapy were included in this study, but data collection on those patients stopped after the sixth course. Individuals involved with data collection at all sites were trained via on-site and/or teleconference training. Site visits were made to assure reliability of at least 0.80. Data were collected and compiled via a fax transmission process that scans directly through optical mark and character recognition into a computer database. Outcome measures included costs of: medications, emergency room visits, physician/clinic/laboratory visits, home healthcare visits, transfusions, special procedures, consultations, hospitalisations and other/miscellaneous costs. MAIN OUTCOME MEASURES AND RESULTS: Of 220 patients, 164 met the study criteria (response rate = 74.2%) with 95 patients in the carboplatin group (NSCLC = 45, SCLC = 18, ovarian = 32) and 69 in the cisplatin group (NSCLC = 36, SCLC = 21, ovarian = 12). The average number of courses were: NSCLC = 4.3 and 4.2, SCLC = 4.3 and 4.8, and ovarian = 4.7 and 5.1, respectively, for carboplatin and cisplatin. The total costs (treatment and toxicity) associated with the use of carboplatin were higher in NSCLC, similar in SCLC but lower in ovarian cancer. CONCLUSIONS: These results indicate that overall treatment costs may vary depending on cancer type, even when the same drugs are used. The total costs (treatment plus toxicity costs) associated with the use of carboplatin were higher than those of cisplatin in patients with NSCLC, similar in SCLC, but lower in ovarian cancer.

Effect of an automated, nursing unit-based drug-dispensing device on medication errors.

The effect of an automated drug-dispensing system on medication error rates was studied. Disguised observations were made on nursing units just before (phase 1) and two months after (phase 2) the implementation of Medstation Rx (Pyxis, San Diego, CA) at a 600-bed hospital. Information gathered included the time of drug administration, the time the medication as ordered to be given, a description of what happened during administration of the dose, and the type of medication error, if any. During phase 1 there were 873 observations and 148 medication errors, for an error rate of 16.9%. During phase 2 the error rate was 10.4% (97 errors in 929 observations). In both study phases, most of the errors were wrong-time errors. The mean +/- S.D. difference between actual and scheduled administration times was 34.5 +/- 48.9 minutes in phase 1 and 30.1 +/- 31.6 minutes in phase 2. Both the decrease in the error rate and the decrease in the departure from scheduled administration times were statistically significant. Medstation Rx was associated with a reduction in the rate of medication errors at a large hospital.

Satisfaction with a computerized practitioner order-entry system at two military health care facilities.

User satisfaction with a computerized practitioner order-entry (POE) system at two military health care facilities was studied. A survey was mailed in May 1998 to providers authorized to enter drug orders into the Composite Health Care System (CHCS) (including two clinical pharmacists) and pharmacy staff members at two department of defense (DOD) medical treatment facilities. Of 189 questionnaires with the potential to be returned completed, 112 were usable, for a net response rate of 59.3%. The internal consistency of the survey items measuring user satisfaction (Cronbach's alpha) was 0.86. The typical respondent was male, was employed by the DOD, had fair to excellent computer and typing skills, had received eight hours or less of training on the CHCS POE system, had been using the system for two years or less, and had been a health care practitioner for 10 years or less. Overall, users were satisfied with the POE system (mean +/- S.D. rating of 3.78 +/- 0.87 on a 5-point scale where 5 represented the highest satisfaction level). Satisfaction was correlated most strongly with ratings of the POE system's efficiency. Nonphysicians were more satisfied, on average, than physicians. No significant relationship was found between other individual characteristics and satisfaction. Qualitative analysis reinforced the finding that users were interested in efficiency issues. Overall, users at two military health care facilities were satisfied with a computerized POE system. Satisfaction was most strongly correlated with the perceived efficiency of the system.

Fax technology for collecting outcomes data in a computer database.

In this era of cost containment, outcomes research is becoming more prevalent. Therefore, various technologies allowing for flexibility in study design and the capture of specific clinical information need to be examined and used. These technologies include fax data systems, pocket scanners, automated telephone equipment, and hand-held computer devices. Fax data systems convert a fax machine into an automated data-entry system. Data-filled forms are faxed to a computer, the fax is converted, and the data are entered into preset fields in a database. Applications for fax systems include acute care-based and ambulatory care-based drug-use evaluations, drug recall systems, and patient-completed surveys of health status. Pocket scanners are hand-held instruments for rapid data entry and transport. Applications for pocket scanning include patient interview responses, procedure and disease analysis, and procedure coding. Options for automated telephone equipment include surveys with interactive voice-mail responses or keypad data entry, pharmacist-monitored drug information and survey services, fax-back and mail-out services, and patient-generated disease intervention programs. Hand-held computer technology is a source of information on multiple protocols and care pathways. All these technologies improve data collection with respect to accuracy and speed, facilitate data analysis, and promote cost-efficient information sharing. The purpose of this study was to evaluate the use of fax technology in data collection for a prospective, multicenter study of the outcomes and cost-effectiveness of two drugs used in the treatment of cancer. Details for the pharmacoeconomic study can be found elsewhere. Fax technology was selected because of the ease with which those responsible for managing the data collection could be trained to use it, the affordability and efficiency of the technology, the ease with which data could be analyzed, and the accuracy of data collection.

Evaluation of mobile cart decentralization.

The purpose of this study was to evaluate the effects of mobile cart decentralization of pharmacy services. The specific objectives of this study were to measure and compare (1) the average time to process a medication order and (2) the satisfaction of the nursing personnel with pharmacy services before and after decentralization. After decentralization, the average medication turn-around time decreased from 30 minutes to 12 minutes. Also, survey results indicate that nursing satisfaction with pharmacy services increased significantly after decentralization. This study measures two important benefits of decentralization. The next step is to measure the costs associated with this system.

Brief review of the literature on decentralized drug distribution in hospitals.

Literature pertaining to decentralization of drug distribution in hospitals since 1972 is reviewed. A chronological list of the articles cited, as well as information on the type of decentralization and outcomes in each article, was compiled. Advantages of decentralization reported in the literature include allowance for expansion of clinical services, more-efficient medication handling, improved communication between pharmacists and medical and nursing staff, decreased floor stock, and decreased medication-related nursing time. Some studies reported that the system minimally increased costs. Although the literature reviewed confirms that decentralization improves the quality of pharmaceutical services, more evidence of cost-effectiveness is needed.

Comparison of women pharmacy and nursing students.

The increasing number of women in pharmacy schools has had an impact on pharmacy manpower estimates. The nursing shortage has been used as an example of what may happen when women health professionals choose not to practice in their field. The purpose of this study was to determine whether the women students in these two health professions were similar with respect to demographics, career choice, career plans, and career commitment. A survey was distributed to undergraduate pharmacy students and baccalaureate nursing students at the University of Texas. The 168 women pharmacy students and 67 nursing students responding to the survey were included in the analyses. On average, the pharmacy students were younger, were more likely to be single, and had fathers of a higher socioeconomic status. When asked to indicate their primary reason for choosing their profession, the pharmacy students most often chose "want a career in the health field," whereas the nursing students chose "desire to help people" most often. When future plans of the two groups were compared, a higher percentage of the pharmacy students planned to work full time for the majority of their careers. Responses to Blau's Career Commitment Scale indicated that the women pharmacy students were more committed to their profession than were women nursing students. Although some may assume these groups are similar, results indicate that there are significant differences between them. Comparison of manpower issues between the two groups may not be justified.

Survey of formulary system policies and procedures.

A telephone survey was conducted to determine the policies and procedures of hospital formulary systems. Directors of pharmacy at a random sample of 150 community hospitals were interviewed, and letters were sent to each respondent requesting copies of the formulary and drug evaluation form. One hundred thirty hospitals completed the interview (gross response rate of 87%), and 35 evaluation forms and 49 printed formularies were received. Almost all hospitals had a formulary system and a printed formulary; the most frequently stated purposes were to decrease costs and to ensure appropriate therapy. Most formularies received were simple drug lists with no supporting information. The typical pharmacy and therapeutics committee consisted of 11 members, met every month, and reported to the executive committee. About 80% of the responding institutions had formal procedures for considering formulary additions. Less than half had standardized drug evaluation forms. Most hospitals have a formulary system and a printed version of the formulary; however, the formulary often serves primarily as a drug list, with no supporting information.

Use of clozapine in Texas state mental health facilities.

Clozapine-use patterns in facilities operated by the Texas Department of Mental Health and Mental Retardation are reported. Data collected by manual and automated tracking systems from January 1990 through July 1992 were analyzed to determine patient demographics, the number of patients started on clozapine and the number who stopped taking the drug, the reasons for discontinuation, and other variables. Of 852 clozapine recipients still in the departmental system by the end of the study period, 134 (16%) had discontinued the drug by that date. There were no significant differences in gender, age, or race between the patients who discontinued the therapy and those who did not. Almost one fourth of the patients who discontinued clozapine therapy did so within the first month, and more than 90% did so within the first year. The most common reasons for discontinuing the medication were lack of clinical response, patient refusal or request, and adverse effects, including agranulocytosis. More women than men discontinued the drug because of adverse effects. Although relatively few patients discontinued clozapine during the study period, many had only recently begun taking the drug, and some of these may discontinue it in the near future. Of 852 clozapine-treated patients served by the Texas Department of Mental Health and Mental Retardation between January 1990 and July 1992, 16% discontinued the therapy. One fourth of these did so within the first month of treatment.

Documenting the value of pharmacist interventions.

The objectives of this study were to measure the incidence and types of pharmacist interventions performed in a community setting in two rural Texas counties; to assign some type of economic value to their services; and to compare these results with those of a previous study of interventions documented by pharmacy student externs and their preceptors. Pharmacists at four pharmacies in two Texas counties agreed to document their interventions on the next 1,500 new prescription orders brought to each pharmacy. The pharmacists first viewed a videotape training program and were instructed on the use of the Pharmacist Intervention Report. Each documented intervention was evaluated independently by a physician and a clinical pharmacist. The dollar value assigned to each of the pharmacists' interventions was the estimated direct cost of medical care avoided through the pharmacist's intervention to correct a prescribing problem. There were 47 interventions documented, representing 0.78% of the 6,000 prescription orders reviewed. The estimated value added by the interventions totaled about $20,000, or about $3.50 per prescription processed.

Benefits of certification for pharmacy specialists.

The objective of the study was to measure the tangible and intangible benefits of certification by the Board of Pharmaceutical Specialties (BPS). All BPS-certified pharmacists (n = .733) were mailed a survey in October 1933. The response rate was 65.5% (n = 480). Approximately 8% of respondents reported a promotion, 16% reported a bonus, and 10% reported a raise as a direct result of certification. Respondents were asked to indicate their level of agreement with statements concerning benefits they had experienced as a result of certification. The highest level of agreement about perceived benefits had to do with greater self-worth, improved competence, and greater marketability. The lowest agreement about perceived benefits was related to monetary compensation. This article compares responses by pharmacists in three specialties and who hold two types of degrees.

Staff pharmacists' opinions about performance appraisals.

Staff pharmacists' knowledge of the performance appraisal (PA) process at their hospitals and their satisfaction with the process were studied. A two-page questionnaire was mailed to staff pharmacists at 11 hospitals located around the country, and a pharmacy administrator at each hospital was interviewed. A total of 142 staff pharmacist surveys were returned. Staff pharmacists' responses about the PA process were then compared with the responses given by their pharmacy administrator. Comparison of responses showed a low percentage of agreement for many items. When process measures were compared with satisfaction scores, the results indicated that staff pharmacists are more satisfied with the PA process when a written performance plan is used and when they receive feedback about their performance throughout the year. Managers should orient staff pharmacists to the PA process that will be used to evaluate them. Written plans for improving performance and frequent feedback about performance may increase staff pharmacists' satisfaction with the PA process.

Work measurement in pharmacy research.

The applicability of various methods of work measurement to pharmacy research is discussed, and studies that have used these methods are reviewed. Methods of work measurement include subjective evaluation, direct time study, work sampling, statistical data, and pre-determined data. Subjective evaluation lacks precision in its estimates but may be useful in formulating hypotheses. Direct time study is most appropriate for readily observable, highly repetitive tasks that can be divided into short segments, although it has been used for longer and more variable activities. Work sampling is the most frequent method of work measurement used in pharmacy research, but few studies reported doing any check of measurement reliability or validity. Multidimensional work sampling and other forms of direct-entry, self-reporting work sampling may be useful in measuring the more complex and unobservable tasks of pharmacists such as clinical activities. By developing an understanding of the purposes and applications of measurement techniques, hospital pharmacists can choose the most appropriate method for their research setting and purpose.

Consumers' evaluation of value-added pharmacy services.

One proposal for community pharmacies to survive in an increasingly competitive market is to offer services that consumers want and need. This study examined the effects of such a value-added pharmacy services (VAPS) program implemented at 19 experimental pharmacies; another 16 pharmacies served as a control group. The study found that patrons of VAPS pharmacies received more pharmacy services and were more likely to report that the pharmacist talked to them about their medication than patrons of control pharmacies. This study demonstrates that a value-added services program can have an impact on pharmaceutical services.