Patient preferences for healthcare delivery through community pharmacy settings in the USA: A discrete choice study.

WHAT IS KNOWN AND OBJECTIVE: In order to improve public health, it is necessary to facilitate patients' easy access to affordable high-quality primary health care, and one enhanced approach to do so may be to provide primary healthcare services in the community pharmacy setting. Discrete choice experiments to evaluate patient demand for services in pharmacy are relatively limited and have been hampered by a focus on only a few service alternatives, most focusing on changes in more traditional pharmacy services. The study aim was to gauge patient preferences explicitly for primary healthcare services that could be delivered through community pharmacy settings in the USA, using a very large sample to accommodate multiple service delivery options. METHODS: An online survey was administered to a total of 9202 adult patients from the general population. A subsequent online survey was administered to 50 payer reimbursement decision-makers. The patient survey included a discrete choice experiment (DCE) which showed competing scenarios describing primary care service offerings. The respondents chose which scenario would be most likely to induce them to switch from their current pharmacy, and an optimal patient primary care service model was derived. The likelihood this model would be reimbursed was then determined in the payer survey. RESULTS AND DISCUSSION: The final optimal service configuration that would maximize patient preference included the pharmacy: offering appointments to see a healthcare provider in the pharmacy, having access to their full medical record, provide point-of-care diagnostic testing, offer health preventive screening, provide limited physical examinations such as measuring vital signs, and drug prescribing in the pharmacy. The optimal model had the pharmacist as the provider; however, little change in demand was evident if the provider was a nurse-practitioner or physician's assistant. The demand for this optimal model was 2-fold higher (25.5%; 95% Bayesian precision interval (BPI) 23.5%-27.0%) than for a base pharmacy offering minimal primary care services (12.6%; 95% BPI 12.2%-13.2%), and was highest among Hispanic (30.6%; 95% BPI: 25.7%-34.3%) and African American patients (30.7%; 95% BPI: 27.1%-35.2%). In the second reimbursement decision-maker survey, the majority (66%) indicated their organization would be likely to reimburse the services described in the optimal patient model if provided in the pharmacy setting. WHAT IS NEW AND CONCLUSION: This United States national study provides empirical support for a model of providing primary care services through community pharmacy settings that would increase access, with the potential to improve the public health.

Adherence to controller asthma medications: 6-month prevalence across a US community pharmacy chain.

WHAT IS KNOWN AND OBJECTIVE: Non-adherence to controller asthma medications is an important public health problem. It is estimated to occur in 30-70% of individuals and is a significant risk factor for asthma morbidity and mortality. The aim of this study was to determine the level of adherence, as indicated by refill rates, to controller asthma medications in a community pharmacy setting. METHODS: Secondary analyses of a community pharmacy dispensing database in 15 locations throughout Utah. RESULTS AND DISCUSSION: The dispensing records of 2193 patients who received controller medications for asthma in a 12-month period, and had a minimum of 6-month potential coverage (180 days) from the date of their first receipt of a controller medication in that period, were examined. Using standard metrics to gauge adherence, the proportion of days covered (PDC) and the medication possession ratio (MPR), the average coverage for controller asthma medications across a 6-month period (180 days) was poor, averaging less than 50% of days' availability. Standard cut-offs (≥80% medication availability) indicated that only 14-16% of patients had 'satisfactory' adherence over their 6-month follow-on period. Females and older patients had significantly greater satisfactory adherence. Medication adherence was significantly greater with inhaled corticosteroid (ICS)-long-acting ß2 -agonist (LABA) combinations than with ICS alone. WHAT IS NEW AND CONCLUSION: This study confirms the considerable scope of the asthma therapy non-adherence problem. Therefore, it is imperative to conduct survey-based research linked directly to pharmacy-based dispensing data to derive patient behavioural, attitudinal and environmental factors that may contribute to the issue, and then pilot and evaluate interventions for change.

DSM-III disorders from age 11 to age 15 years.

Although research into the continuity of disorder from childhood to adolescence is sparse, results from both longitudinal and cross sectional studies suggest that the prevalence of disorder increases for girls but may remain more stable for boys. In this paper, the methodologies of two assessment phases of the Dunedin longitudinal study have been equated to estimate the continuity of DSM-III disorder from ages 11 to 15. Although the overall prevalence of disorder doubled between the ages, this was primarily because of an increase in nonaggressive conduct disorder and major depressive episode. The sex ratios in disorder had largely reversed from a male predominance at 11 to a female predominance at 15. In terms of persistence, over 40% of those with disorder at age 11 were also identified at age 15. However, over 80% of those identified with disorder at 15 did not have a history of disorder at 11. Significant sex differences were also found in the continuity of internalizing and externalizing disorders, with externalizing disorders showing more continuity for boys, and internalizing for girls. Logistic regression models were employed to evaluate the roles family background, academic and social competence, and early histories of behavior problems may play in the determination of disorder continuity.

Mental health disorders from age 15 to age 18 years.

OBJECTIVE: To determine the strength of association between mental health disorders in adolescence and disorder in early adulthood. METHOD: The study used mental health data from a longitudinal investigation of a New Zealand birth cohort. Of the 943 with prevalence data for DSM-III disorder at age 15, 890 had prevalence data for DSM-III-R disorder when aged 18 years. RESULTS: Two-thirds of those with disorder at age 15 had disorder at age 18. The residual form of attention deficit disorder, simple phobias, and oppositional disorders (with no other accompanying disorders) were associated with the lowest risk of later disorder and conduct disorder with the highest. With the exception of the overall symptom level, a variety of characteristics examined (e.g., social competence and adversity) could not differentiate between those with transient disorder and those with disorder at both ages. Comparisons of those with recurring disorder and those with new disorder at age 18 showed that in addition to characteristics of the disorder, disadvantage was strongly associated with recurrent disorder. CONCLUSIONS: The risk of later disorder for those with disorder in adolescence was high and differed across type of disorder. Findings suggest that to reduce the risk of disorder in early adulthood, clinicians could play a more active role in community interventions with direct social outcomes.

Prevalence and correlates of the premenstrual syndrome in adolescence.

In a longitudinal study of their health and development, 384 15-year-old females reported their experience of symptoms indicative of premenstrual syndrome (PMS). The prevalence of these symptoms is reported and a group of adolescents is identified with the syndrome (14%). PMS was associated with current self-reported anxiety, inattention, and poor health. Preadolescent self-report and maternal ratings of physical and mental health did not significantly predict adolescent PMS. The results suggest that the experience of PMS in adolescence may be mediated by perceived health status; the roles of mental health and maternal influence in the development of adolescent PMS may be minimal.

Models of adolescent psychopathology: childhood risk and the transition to adulthood.

OBJECTIVE: To examine the relationship between DSM-III disorder in adolescence (age 15 years) and DSM-III-R disorder in early adulthood (age 18 years), in relation to a history of behavior problems or disorder, other family and individual characteristics, and events commonly associated with the transition to adulthood. METHOD: The sample came from a New Zealand birth cohort selected from the general population. Data were obtained from ages 3 to 18 years for 890 of those enrolled. RESULTS: For both males and females, disorder at age 15 was strongly predicted by histories of early mental health problems. However, neither those histories, background characteristics, nor the experience of adolescent transition events modified the strength of association between disorder at ages 15 and 18 years. In childhood, after adjusting for histories of behavior problems, parental separations and (for boys) poor social competence remained independent predictors of disorder at age 15. Overall, boys appeared more vulnerable and those from socially disadvantaged backgrounds in early childhood had an elevated risk of disorder at age 18. After adjusting for disorder at age 15, adolescent unemployment remained an independent predictor of disorder at age 18 for both males and females. CONCLUSIONS: This study modeled the continuity of disorder across the adolescent transition period and, after taking earlier disorder into account, identified clear predictors of later disorder. This is the first step in the process of developing more effective interventions to reduce the risk of mental health disorders.

DSM-III disorders in a large sample of adolescents.

The prevalence of DSM-III disorders was studied in 943 adolescents aged 15 years from a general population. Prevalence rates of disorder of 25.9% for girls and 18.2% for boys were found. The most prevalent disorders were overanxious disorder, nonaggressive conduct disorder, and simple phobia. Marked differences were noted among the disorders in terms of associated social competence, with multiple disorders and primarily "externalizing" disorders being related to poorer competence. A model of parental confirmation of disorder was developed suggesting that confirmation was more likely where the mother was depressed, the family low in social support, and the adolescent less socially competent.

Self-reported inattention, impulsivity, and hyperactivity at ages 15 and 18 years in the general population.

OBJECTIVE: Prevalence, impact, and continuity of self-reported attention deficit disorder (ADD) symptomology from ages 15 to 18 years were examined in a longitudinal study of a New Zealand birth cohort. METHOD: At age 15, prevalence of ADD symptomology was estimated, with no gender differences found in self-reported symptomology. Four adolescents (0.5%) met full DSM-III criteria for ADD. Adolescents scoring higher than 1.5 SD above the sample mean on total ADD symptom score were identified as having high levels of ADD symptomology. RESULTS: Male and female adolescents reporting ADD symptomology with (6% of males; 4% of females) and without history of behavior disorder (6% of males; 7% of females) did not differ in inattention and impulsivity, received more diagnoses other than ADD, and experienced more adverse educational and social outcomes at 15 and 18 years than did the nonADD group. CONCLUSIONS: Findings pertaining to the ADD with history group were consistent with previous research on the outcome of hyperactive children, whereas the ADD without history group may be reflecting the onset of other pathology in adolescence. Results suggest adolescent self-report of attentional difficulties may be a clinically significant marker of adjustment difficulties for both males and females, but additional information likely is needed for accurate diagnosis.

The New Zealand Rugby Injury and Performance Project: alcohol use patterns within a cohort of rugby players.

Although heavy drinking has traditionally been associated with rugby, the drinking patterns of New Zealand rugby players have not been examined. Three hundred and forty-eight rugby players (257 males and 91 females), completed the Alcohol Use Disorders Identification Test (AUDIT) at the beginning of the 1993 rugby season. The mean AUDIT scores were 11.2 (SD = 5.1) for the males and 8.7 (4.1) for the females: a cut-off of 8.0 has been recommended by the developers of the instrument for identifying alcohol use disorders. The consumption of large quantities of alcohol, and a high frequency of heavy drinking sessions were the norm for this group. Sixty-one per cent of males and 38% of females consumed six or more drinks in a session at least weekly: typically, men drank 10 or more drinks in a session and women 5-6 drinks. The patterns of drinking exhibited by the cohort give cause for concern regarding the health risks associated with such behaviour.

Is there an association between lateral preference and delinquent behavior?

Results of recent research suggests an association between left lateral preference and delinquent behavior. In this study the lateral preferences of 881 seven-year-old children were determined using behavioral indicators of hand and foot use. Mixed-handedness was associated with parent-reported problem behavior scores and self-reported delinquency scores at ages 13 and 15. However, preference for left hand and foot use was found to be unrelated to the delinquency measures. The distribution of lateral preferences in an identified delinquent group was not significantly different from the distribution in the sample remainder. The lack of an association between left preference and delinquency may be accounted for by an increased cultural acceptance of individual preference.

Handedness and allergic disorders in a New Zealand cohort.

Studies of the proposed association between handedness and allergic disorders have shown results which appear contradictory. In view of differences in the procedures of these studies, further tests of the strength of this association are warranted. Results from this study of a large birth cohort of children showed no support for an association between handedness measured at age 7 years and reports of eczema, urticaria, rhinitis, or asthma in late childhood or early adolescence. There was no significant association found between handedness and reported frequency and duration of symptoms of wheezing, or parental help-seeking for these symptoms. Apparent differences in the results of these studies could possibly be reconciled by the view that preference for use of the left hand may be associated with increased help-seeking behaviour in later life for a range of problems or difficulties. Further tests of the association between handedness and disorder in clinical samples require more rigorous control procedures.

Use of protective equipment in a cohort of rugby players.

PURPOSE: To describe the level of usage of protective devices and equipment in a cohort of New Zealand rugby players. METHODS: Male and female players (N = 327) from a range of competitive grades were followed over the course of the season. Participants were interviewed weekly about their participation in rugby and use of protective equipment. The main outcome measure was percentage of all player-weeks of follow-up for which each equipment item was used. RESULTS: Mouthguards, the most commonly used equipment item, were worn for 64.9% of player-weeks. Mouthguard usage ranged from 55.0% of player-weeks in Schoolgirls grade to 72.9% of player-weeks in Senior A competition. The next most common item was taping of body joints (23.7% of player-weeks). The sites most commonly taped were the ankle, knee, and hand. Overall usage for the other protective equipment items studied (shin guards, padded headgear, head tape, support sleeves, and grease) was below 15%. In general, forwards had higher usage of protective equipment than backs, and male players had higher usage than female players. The most common self-reported reasons for using protective equipment were to prevent injury and because of a past injury. Players exhibited considerable week-to-week variation in their usage of protective equipment. CONCLUSIONS: In general, equipment usage was highest in those at greatest risk of injury, namely, forwards, male players, and the senior grades. The high voluntary use of mouthguards is encouraging and indicative of a base of player support for their role in this sport.

Alcoholism treatment and the family: do family and individual treatments for alcoholic adults have preventive effects for children?

OBJECTIVE: This article identifies findings on alcoholism treatment and the family that may have implications for prevention of mental health and substance abuse problems in children. METHOD: We conducted a brief overview of research on family treatment for alcoholism and on family adjustment after individual treatment for the alcoholic. RESULTS: Behavioral couples therapy with alcoholics and remission after individual alcoholism treatment have been associated with improved family functioning in a variety of domains, including reduced family stressors; improved marital adjustment; reduced domestic violence and verbal conflict; reduced risk of separation and divorce; improvement in important family processes related to cohesion, conflict and caring; and reduced emotional distress in spouses. These family factors have been linked with child mental health and psychosocial functioning in more general child developmental and psychopathology studies. CONCLUSIONS: Research is needed to find out whether behavioral couples therapy or individual treatment for an alcoholic parent has beneficial and preventive effects for children, reducing their risk for mental health and substance abuse problems. Studies should determine whether there is a specific link between (a) improvements in family stressors, violence and verbal aggression, marital adjustment and stability and (b) child, adolescent and young adult outcomes for the children in these families.

Behavioral couples therapy versus individual-based treatment for male substance-abusing patients. An evaluation of significant individual change and comparison of improvement rates.

Fals-Stewart, Birchler, and O'Farrell (1996) found that married or cohabiting substance-abusing men (n = 40) who participated in behavioral couples therapy (BCT) in addition to individual-based treatment (IBT) for substance abuse had fewer days of substance use and, along with their partners, reported higher levels of dyadic adjustment during and 1-year after treatment than husbands who received IBT only (n = 40). In the present study, significant individual change in posttreatment frequency of substance use and dyadic adjustment was evaluated and comparisons of the proportions of participants receiving IBT and BCT who were improved, unchanged, or deteriorated in these domains of functioning were made using data from Fals-Stewart et al. (1996). Growth curve analysis revealed that a larger proportion of husbands in the BCT condition showed significant reductions in substance use (n = 33, 83%) than husbands who received IBT (n = 24, 60%). Also, a larger proportion of couples who participated in BCT showed improvements in dyadic adjustment (n = 24, 60%) than couples whose husbands received IBT only (n = 14, 35%).

Attention deficit disorder and age of onset of problem behaviors.

In the course of a prospective longitudinal study, we examined age of onset of behavior problems in a group of boys and girls identified with attention deficit disorder (ADD) at age 11. Onset occurred during the preschool years, by the first year of schooling, or by the end of the second year of school. Onset was strongly related to informant source at age 11, pattern of comorbidity of disorder at age 11, and developmental language, perceptual motor, and IQ measures. Onset by the first year of schooling was particularly related to poor reading skills. By age 15, nearly three-quarters of those with onset of problems before age 6 had one or more DSM-III disorders.

The importance of conduct problems and depressive symptoms in predicting adolescent substance use.

The current study assessed the relative importance of conduct problems and depressive symptoms, measured at two ages (11 and 15), for predicting substance use at age 15 in an unselected birth cohort of New Zealand adolescents. Among males, when the relative predictive utility of both conduct problems and depressive symptoms was assessed, only pre-adolescent depressive symptoms were found to predict multiple drug use 4 years later. No predictive relation was found between early symptomatology and later substance use among females. The strongest association between predictors and substance use emerged between age 15 multiple drug use and concurrent conduct problems for both males and females. Finally, both conduct problems and depressive symptoms at age 15 were also found to be associated with concurrent "self-medication" among females.

Strict and inconsistent discipline in childhood: consequences for adolescent mental health.

Recent reviews have suggested an association between discipline experienced in childhood and the development of later psychopathology. As part of a longitudinal study of the health and development of a large sample of New Zealand children, maternal reports of strict and inconsistent discipline were obtained when the sample members were aged 7 and 9 years. It was found that inconsistency was associated with early behaviour problems, but strictness was not. At age 15 years the prevalence of DSM-III disorders in the sample was established. Univariate analyses showed significant associations between inconsistency and low levels of strictness with externalizing disorder. Logistic regression analyses demonstrated that in the presence of other predictor variables including childhood problem behaviour, these associations only approached significance. However, when the two ratings were combined, rates of disorder for those who experienced more relaxed and inconsistent discipline were double the rates found in the sample remainder. No significant association was found between discipline and internalizing disorder.

A longitudinal study of birth order, help seeking and psychopathology.

Recent studies have suggested an association between birth order and psychopathology. However, the association remains unclear due to a lack of consideration of the confounding effects of family size. At age seven years the family size and birth order of children from a large cohort of New Zealand children were examined in relation to parental help seeking for behavioural and emotional problems, and the development of DSM-III (American Psychiatric Association, 1980) disorder in pre-adolescence and adolescence. Neither the child's gender, birth order nor family size were associated with parental help seeking or the prevalence of DSM-III disorder in pre-adolescence at age 11. In adolescence at age 15, however, significantly more girls, first-borns and children from small families had DSM-III disorder, but the interactions between these factors were not significant. In particular, these associations were found with internalizing disorders. The appropriateness of further studies of birth order in relation to psychopathology is discussed.

The reduction of bruxism using contingent EMG audible biofeedback: a case study.

This report describes the use of EMG biofeedback to reduce bruxism in an 18-year-old woman. The behaviour was severe and not responsive to standard dental treatment. In addition to psychometric measures of affective status, objective measures of both the frequency and intensity of bruxing incidents were made, and a 4-week intervention conducted. On the bruxing and affective measures significant improvements were noted, as were reductions in associated pain and dysfunction.

Physical assault in New Zealand: the experience of 21 year old men and women in a community sample.

AIM: To obtain epidemiological information on physical assault in a high risk group of New Zealanders. METHOD: Rates of physical assault in the preceding twelve months were ascertained by interview in a cohort of 21 year old, Dunedin-born men (n = 482) and women (n = 462). RESULTS: Forty-five percent of the men and one quarter of the women reported at least one physical assault, either completed, attempted or threatened. A small proportion of these received medical treatment. Most serious assaults were by a perpetrator who was thought to have been drinking alcohol. Most assaults on men were by strangers but partners carried out more assaults against women, especially those receiving medical treatment. One quarter of all assaults on women were by other women, compared to 15% of the assaults on men. Differences between patterns of assaults on women and on men are discussed. CONCLUSION: It is important for doctors to be aware of the widespread occurrence of interpersonal violence in New Zealand and its underreporting.