Does Medicaid payer status affect patient's shoulder outcomes after shoulder arthroplasty?

BACKGROUND: Low socioeconomic status and Medicaid insurance as a primary payer have been shown to influence resource utilization and risk-adjusted outcomes for total joint arthroplasty. The purpose of this study was to assess the effects of Medicaid primary payer status on outcomes following shoulder arthroplasty (SA). MATERIALS AND METHODS: A retrospective review of shoulder surgery patients was undertaken to identify a matched cohort of 51 patients who underwent SA and were stratified based on insurance type into two cohorts: 28 Medicaid (M) patients and 23 non-Medicaid (NM) patients. Baseline demographics, resource utilization, and outcomes were compared as well as pre-and-postoperative patient-reported outcomes (PRO) and functional scores. PRO scores included the American shoulder and elbow surgeons score (ASES), the Penn shoulder score (PSS), and the subjective shoulder value (SSV). RESULTS: There were no statistically significant differences in demographics, comorbidities, or preoperative baseline scores between the cohorts, except for age (M: 55.3 years; NM: 67.5 years; p ≤ 0.001) and smoking status (M: 13 patients; NM: 4 patients; p = 0.029). Medicaid patients showed a slightly higher rate of missed follow-ups (M: 1.1 vs. NM: 0.9; p = 0.370). All Medicaid and non-Medicaid patients experienced significant improvement on PRO scores and active forward flexion. Medicaid patients demonstrated equivalent final postoperative scores for ASES (M: 65; NM: 57; p = 0.454), PSS (M: 63; NM: 51; p = 0.242), SSV (M: 70; NM: 69; p = 1.0) and range of motion measurements. DISCUSSION: Overall results suggest that Medicaid patients can expect significant improvement after SA and the same level of PRO's compared to non-Medicaid-insured population. LEVEL OF EVIDENCE: Level III, Retrospective Comparative Design, Treatment Study.

Cost-effectiveness of multidisciplinary collaborative care versus usual care in the management of high-risk patients with diabetes in Singapore: Short-term results from a randomized controlled trial.

WHAT IS KNOWN AND OBJECTIVE: Economic evidence of multidisciplinary collaborative care on glycaemic improvement in uncontrolled diabetic patients is limited. Therefore, the primary objective of this study was to assess the cost-effectiveness of multidisciplinary collaborative care versus usual care and the secondary objective was to assess the cost-effectiveness of these two care approaches in relation to varying glycaemic control of patients. METHODS: An economic evaluation based on a six-month randomized controlled trial involving high-risk uncontrolled diabetic Asian patients with polypharmacy and multiple comorbidities was conducted from a healthcare institution perspective. The control arm received usual care, while the intervention arm received multidisciplinary care with regular clinical pharmacist follow-up in addition to usual care. The study outcomes included glycated haemoglobin (HbA1c) change and total direct outpatient medical costs for diabetes-related care. The cost-effectiveness analyses were conducted for both arms and those stratified according to baseline HbA1c (Group 1:HbA1c 7.1%-7.9%, Group 2:HbA1c ≥8.0%). The incremental cost per glycaemic improvement (HbA1c improvement of 0.1% and above) per patient was examined followed by uncertainty evaluation via probabilistic sensitivity analyses. A range of willingness-to-pay (WTP) thresholds (US$165.21 to US$5000.00 per glycaemic improvement) was used in analysis. RESULTS AND DISCUSSION: Overall, the intervention arm had greater improvement in HbA1c (I: mean -0.4% [95% CI -0.6 to -0.2] vs C: mean -0.1% [95% CI -0.2 to 0.1]; P = .014) and lower mean total direct outpatient medical costs per patient in comparison with the control arm (I: US$516.77 ± 222.10 vs C: US$607.78 ± 268.39; P < .001). The intervention arm was the dominant strategy across varying baseline HbA1c with higher probability of Group 2 being cost-effective at higher WTP threshold. WHAT IS NEW AND CONCLUSIONS: The multidisciplinary collaborative care arm was cost-effective in managing Asian patients with varying baseline HbA1c control. The multidisciplinary collaborative care also showed greater probability of being cost-effective among Asian patients with poorly uncontrolled glycaemia.

The effect of Medicaid payer status on patient outcomes following repair of massive rotator cuff tears.

BACKGROUND: The influence of socioeconomic status and insurance type has not been studied extensively for RCR, particularly not in the high risk massive RCT population. The purpose of this study is to identify relationships between Medicaid payer status and patient outcomes following massive RCR. METHODS: A retrospective review of shoulder surgery database identified 29 patients undergoing massive rotator cuff repair. Patients were stratified based on insurance type into two cohorts, Medicaid (14 patients) and non-Medicaid (15 patients). Missed routine follow-up appointments and comorbidities were recorded and compared between groups. Group comparisons were made for pre- and postoperative patient-reported and functional outcomes. Outcome scores included American Shoulder and Elbow Shoulder Score (ASES), the Penn Shoulder Score, and the Subjective Shoulder Value (SSV). A p value of < 0.05 was considered significant for all statistical analyses. RESULTS: Medicaid patients were on average 7.1 years younger than non-Medicaid patients (49.8 vs. 56.9 years, respectively), and remaining demographics were comparable between groups. Preoperative patient-reported outcomes were only significantly different for ASES and ASES pain (p = 0.010, 0.037). There was excellent average improvement for Medicaid patients but no significant differences compared to non-Medicaid patients for ASES (p = 0.630), PENN scores (p = 0.395), and SSV (p = 0.198). Medicaid patients also had a higher number of missed and canceled appointments (28%) compared to non-Medicaid patients (18%). CONCLUSION: Medicaid coverage will expand to millions of uninsured Americans under current healthcare reform. Medicaid patients with massive RCT appear to significantly improve with surgical treatment.

Impact of pharmacist-involved collaborative care on the clinical, humanistic and cost outcomes of high-risk patients with type 2 diabetes (IMPACT): a randomized controlled trial.

WHAT IS KNOWN AND OBJECTIVE: With the increasing prevalence of diabetes, the physician-centred model is challenged to deliver holistic care in Asia. Diabetes may be managed effectively within a multidisciplinary collaborative care model; however, evidence on its effectiveness in Asian patients is lacking. Therefore, the primary objective was to evaluate the clinical outcomes of multidisciplinary collaborative care vs physician-centred care in diabetes. The secondary objectives were to evaluate humanistic and economic outcomes among the two types of care. METHODS: This 6-month prospective, open-label, parallel-arm, randomized, controlled study was conducted at four outpatient healthcare institutions. High-risk patients aged ≥21 years with uncontrolled type 2 diabetes, polypharmacy and comorbidities were included. Patients with type 1 diabetes or those who were unable to communicate independently were excluded. The control arm received usual care with referrals to nurses and dietitians as needed. The intervention arm (multidisciplinary collaborative care) was followed up with pharmacists regularly, in addition to receiving the usual care. The primary outcomes included HbA1c, systolic blood pressure, low-density lipoprotein and triglycerides. The secondary outcomes included scores from the Problem Areas in Diabetes (PAID) and the Diabetes Treatment Satisfaction Questionnaires (DTSQ), and diabetes-related health service utilization rates and costs. RESULTS AND DISCUSSION: Of 411 eligible patients, 214 and 197 patients were randomized into the intervention and control arms, respectively. At 6 months, 141 patients in the intervention arm (65.9%) and 189 patients in the control arm (95.9%) completed the study. Mean HbA1c reduced from 8.6%±1.5% at baseline to 8.1%±1.3% at 6 months in the intervention arm (P=.04), with up to mean HbA1c improvement of 0.8% in patients with greater levels of uncontrolled glycemia. Whereas the mean HbA1c in the control arm remained unchanged (8.5%±1.4%) throughout the 6-month period. Improvements in PAID and DTSQ scores, reduction in physician workload and an average cost savings of US$91.01 per patient were observed in the intervention arm over 6 months. WHAT IS NEW AND CONCLUSIONS: The positive clinical, humanistic and economic outcomes highlighted the value of multidisciplinary collaborative care for Asian diabetic patients, thereby supporting the effectiveness of this approach in managing chronic diseases.

A claims-based Markov model for Crohn's disease.

BACKGROUND: Crohn's disease is a chronic condition that often presents in early adulthood. AIM: To evaluate health care costs and costs per quality-adjusted life year (QALY) for Crohn's disease. METHODS: A Markov model was developed using administrative claims data for patients aged > or = 18 years with > or = 3 years of continuous enrolment from 2000 to 2008 and > or =2 Crohn's disease claims. Disease states (remission, mild-moderate, moderate-severe, and severe-fulminant) were defined using the American College of Gastroenterology treatment guidelines criteria. Transition probabilities were calculated from consecutive 6-month periods. Costs were determined from paid claims and QALY utilities were obtained from the literature. The model assumed a 30-year-old patient at the time of entry into the model. RESULTS: There were 40 063 patients identified, with a total of 420 773 cycles [remission (197 111; 46.8%), mild-moderate (44 024; 10.5%), moderate-severe (132 695; 31.5%), severe-fulminant (46 925; 11.2%)]. The costs/QALY for remission, mild-moderate, moderate-severe, and severe-fulminant disease states respectively were $2896, $8428, $11 518 and $69 277 for males and $2896, $8426, $22 633 and $69 412 for females. CONCLUSIONS: Overall, health care costs for patients with Crohn's disease increased with disease severity. Although the probabilities of transitioning from other health states to the severe-fulminant disease state were low, the cost/QALY was high.

Health care utilization and costs by metabolic syndrome risk factors.

BACKGROUND: This study compared prevalent health utilization and costs for persons with and without metabolic syndrome and investigated the independent associations of the various factors that make up metabolic syndrome. METHODS: Subjects were enrollees of three health plans who had all clinical measurements (blood pressure, fasting plasma glucose, body mass index, triglycerides, and high-density lipoprotein cholesterol) necessary to determine metabolic syndrome risk factors over the 2-year study period (n = 170,648). We used clinical values, International Classification of Diseases, Ninth Revision (ICD-9) diagnoses, and medication dispensings to identify risk factors. We report unadjusted mean annual utilization and modeled mean annual costs adjusting for age, sex, and co-morbidity. RESULTS: Subjects with metabolic syndrome (n = 98,091) had higher utilization and costs compared to subjects with no metabolic syndrome (n = 72,557) overall, and when stratified by diabetes (P < 0.001). Average annual total costs between subjects with metabolic syndrome versus no metabolic syndrome differed by a magnitude of 1.6 overall ($5,732 vs. $3,581), and a magnitude of 1.3 when stratified by diabetes (diabetes, $7,896 vs. $6,038; no diabetes, $4,476 vs. $3,422). Overall, total costs increased by an average of 24% per additional risk factor (P < 0.001). Costs and utilization differed by risk factor clusters, but the more prevalent clusters were not necessarily the most costly. Costs for subjects with diabetes plus weight risk, dyslipidemia, and hypertension were almost double the costs for subjects with prediabetes plus similar risk factors ($8,067 vs. $4,638). CONCLUSIONS: Metabolic syndrome, number of risk factors, and specific combinations of risk factors are markers for high utilization and costs among patients receiving medical care. Diabetes and certain risk clusters are major drivers of utilization and costs.

Hydrofluoroalkane-134a beclomethasone as a dominant economic asthma therapy.

Inhaled corticosteroids for asthma treatment have become mainstay of therapy for patients with persistent asthma. Numerous inhaled corticosteroids are available but to date no prospective cost-effectiveness studies have been reported using exclusively US patients and costs. The purpose of this study was to examine the cost-effectiveness of HFA-bectomethasone (QVAR) compared to CFC-beclomethasone (Vanceril) using data from a year-long prospective randomized, open label, parallel multicenter trial. Eligibility criteria required patients to have been on a stable dose of CFC-BDP prior to enrollment. Patients were randomized to either HFA-BDP at approximately half their previous daily dose of CFC-BDP or to continue CFC-BDP Effectiveness data, in terms of symptom-free days (SFDs), were used in a cost-effectiveness analysis conducted from the viewpoint of managed care. Patients receiving HFA-BDP reported a greater increase (median = 22.1) in the number of SFDs than those receiving CFC-BDP (median = 14.3) (P = 0.03). Total costs of care were less for patients taking HFA-BDP (median = dollars 668) compared to CFC-BDP (median = dollars 977). The median incremental cost-effectiveness ratio was dollars -5.77 (95% CI: dollars -68.08 to dollars -4.08). The results of this analysis indicate that HFA-BDP was a dominant therapy (more effective, less costly) compared to CFC-BDP.

Excessive antibiotic use for acute respiratory infections in the United States.

Estimating the amount and cost of excess antibiotic use in ambulatory practice and identifying the conditions that account for most excess use are necessary to guide intervention and policy decisions. Data from the 1998 National Ambulatory Medical Care Survey, a sample survey of United States ambulatory physician practices, was used to estimate primary care office visits and antibiotic prescription rates for acute respiratory infections. Weight-averaged antibiotic costs were calculated with use of 1996 prescription marketing data and adjusted for inflation. In 1998, an estimated 76 million primary care office visits for acute respiratory infections resulted in 41 million antibiotic prescriptions. Antibiotic prescriptions in excess of the number expected to treat bacterial infections amounted to 55% (22.6 million) of all antibiotics prescribed for acute respiratory infections, at a cost of approximately $726 million. Upper respiratory tract infections (not otherwise specified), pharyngitis, and bronchitis were the conditions associated with the greatest amount of excess use. This study documents that the amount and cost of excessive antibiotic use for acute respiratory infections by primary care physicians are substantial and establishes potential target rates for antibiotic treatment of selected conditions.

Economic burden of asthma: implications for outcomes and cost-effectiveness analyses.

Asthma is a disease of chronic airway inflammation. It is of importance to clinicians and health systems because the hospitalization and death rate due to asthma have increased since 1980. Cost of illness studies have estimated that the total cost of asthma (direct and indirect costs) exceed USD 10 billion annually, in the USA. Since 1985, the proportion of asthma costs in hospitals have decreased and the proportion of costs due to asthma medications have increased. However, approximately half of direct medical costs of asthma are due to hospitalizations. The mean direct cost of asthma per year per patient has been estimated to be approximately USD 1,100. As the implementation of national and international guidelines continues, future costs for asthma will likely come from the treatment and management of the disease. Adequate assessments of treatment and cost-effectiveness analysis are important. Recommendations promoting the use of cost-effective anti-inflammatory medications are crucial to efficiently managing asthma.

Clinical and economic impact of ambulatory care clinical pharmacists in management of dyslipidemia in older adults: the IMPROVE study. Impact of Managed Pharmaceutical Care on Resource Utilization and Outcomes in Veterans Affairs Medical Centers.

We examined the impact of ambulatory care clinical pharmacist interventions on clinical and economic outcomes of 208 patients with dyslipidemia and 229 controls treated at nine Veterans Affairs medical centers. This was a randomized, controlled trial involving patients at high risk of drug-related problems. Only those with dyslipidemia are reported here. In addition to usual medical care, clinical pharmacists were responsible for providing pharmaceutical care for patients in the intervention group. The control group did not receive pharmaceutical care. Seventy-two percent of the intervention group and 70% of controls required secondary prevention according to the National Cholesterol Education Program guidelines. Significantly more patients in the intervention group had a fasting lipid profile compared with controls (p=0.021). The absolute change in total cholesterol (17.7 vs 7.4 mg/dl, p=0.028) and low-density lipoprotein (23.4 vs 12.8 mg/dl, p=0.042) was greater in the intervention than in the control group. There were no differences in patients achieving goal lipid values or in overall costs despite increased visits to pharmacists. Ambulatory care clinical pharmacists can significantly improve dyslipidemia in a practice setting designed to manage many medical and drug-related problems.

Applying 'technology assessment' and 'evidence based medicine' theory to interventional radiology. Part 1: Suggestions for the phased evaluation of new procedures.

AIM: To compare and contrast interventional radiology (IR) clinical and research practices with the technology assessment and evidence-based medicine (EBM) paradigms and make suggestions for the phased evaluation of new IR procedures. MATERIALS AND METHODS: Course literature of the Association of University Radiologists' 'Basic Technology Assessment for Radiologists' course and the McMaster University Health Information Research Unit's 'How to Teach Evidence-Based Medicine 1999' course were used to identify major publications in each discipline. A computer search was performed to seek other relevant literature. A model of traditional development of IR procedures was developed. Suggestions for the phased evaluation of IR procedures were derived. RESULTS: As in diagnostic radiology, several levels of progressively stronger IR study design can be described and related to EBM 'levels of evidence'. These range from case reports and case series through case-control and cohort studies to randomized controlled trials (RCTs). The major weakness in the existing IR literature is the predominance of small, uncontrolled, case series. Randomized controlled trials are likely to provide the best possible evidence of effectiveness. They are expensive and randomization is sometimes unethical or impractical. Case-control and cohort studies have been under-utilized. Evidence-based medicine indices of benefit and harm have not yet been applied in IR and may have clinical advantages over traditional statistical methods. A literature search (10 years) using MeSH terms 'radiology, interventional' and 'efficacy' yielded 30 papers. Combining 'radiology, interventional' and 'evidence-based medicine' yielded no papers. Comparative searches substituting the term 'diagnostic imaging' for 'radiology, interventional' yielded 4883 and 62 papers, respectively. CONCLUSION: Principles of technology assessment and EBM can be applied to the investigation of new IR procedures. A tool is needed to simplify the application of EBM analytic methods. Better education in research methods is needed to raise the levels of evidence provided by the bulk of IR research and allow new procedures to be introduced into practice appropriately. Malone, D. E. & MacEneaney, P. M. (2000). Clinical Radiology55, 929-937.

Applying 'evidence-based medicine' theory to interventional radiology. Part 2: a spreadsheet for swift assessment of procedural benefit and harm.

AIM: To design a spreadsheet program to analyse interventional radiology (IR) data rapidly produced in local research or reported in the literature using 'evidence-based medicine' (EBM) parameters of treatment benefit and harm. MATERIALS AND METHODS: Microsoft Excel(TM)was used. The spreadsheet consists of three worksheets. The first shows the 'Levels of Evidence and Grades of Recommendations' that can be assigned to therapeutic studies as defined by the Oxford Centre for EBM. The second and third worksheets facilitate the EBM assessment of therapeutic benefit and harm. Validity criteria are described. These include the assessment of the adequacy of sample size in the detection of possible procedural complications. A contingency (2 x 2) table for raw data on comparative outcomes in treated patients and controls has been incorporated. Formulae for EBM calculations are related to these numerators and denominators in the spreadsheet. The parameters calculated are benefit - relative risk reduction, absolute risk reduction, number needed to treat (NNT). Harm - relative risk, relative odds, number needed to harm (NNH). Ninety-five per cent confidence intervals are calculated for all these indices. The results change automatically when the data in the therapeutic outcome cells are changed. A final section allows the user to correct the NNT or NNH in their application to individual patients. RESULTS: This spreadsheet can be used on desktop and palmtop computers. The MS Excel(TM)version can be downloaded via the Internet from the URL ftp://radiography.com/pub/TxHarm00.xls. CONCLUSION: A spreadsheet is useful for the rapid analysis of the clinical benefit and harm from IR procedures.

An economic analysis of a randomized, controlled, multicenter study of clinical pharmacist interventions for high-risk veterans: the IMPROVE study. Impact of Managed Pharmaceutical Care Resource Utilization and Outcomes in Veterans Affairs Medical Centers.

STUDY OBJECTIVE: To determine if clinical pharmacists could affect economic resource use and humanistic outcomes in an ambulatory, high-risk population. DESIGN: Prospective, randomized, controlled study. SETTING: Nine Veterans Affairs medical centers. PATIENTS: Patients who were at high risk for medication-related problems. INTERVENTION: Patients were randomized to usual medical care with input from a clinical pharmacist (intervention group) or just usual medical care (control group). MEASUREMENTS AND MAIN RESULTS: Of 1,054 patients enrolled, 523 were randomized to the intervention group and 531 to the control group. The number of clinic visits increased in the intervention group (p=0.003), but there was no difference in clinic costs. Mean increases in total health care costs were $1,020 for the intervention group and $1,313 for the control group (p=0.06). CONCLUSION: Including the cost of pharmacist interventions, overall health care expenditures were similar for patients randomized to see a clinical pharmacist versus usual medical care.

Costs of beta-lactam allergies: selection and costs of antibiotics for patients with a reported beta-lactam allergy.

OBJECTIVE: To evaluate antibiotic selection and the cost effect of reported beta-lactam allergies. DESIGN: Retrospective medical records review comparing antimicrobial selection and costs in patients with a reported beta-lactam allergy with a group in which no such allergy had been documented. SETTING: University-based family medicine clinic. PATIENTS: Patients who were prescribed at least 1 antibiotic for an upper respiratory tract infection, otitis media, sinusitis, and/or a urinary tract infection were eligible. One thousand two hundred one patients were identified via ICD-9-CM (International Classification of Diseases, Ninth Revision, Clinical Modification) codes. Four hundred sixty-five patients were initially identified and an additional 195 family members were eligible for inclusion. MAIN OUTCOME MEASURES: Comparison of antimicrobial selection and costs (by average wholesale price) between patients with and without a reported beta-lactam allergy. RESULTS: Of the 660 patients eligible for inclusion, 99 (15%) had a documented beta-lactam allergy. Of the patients with a documented allergy, only 33% had a description of their purported reaction. The mean antibiotic cost for patients with a beta-lactam allergy was significantly higher compared with those without a beta-lactam allergy ($26.81 vs $16.28, respectively; P =.004). Patients with a beta-lactam allergy were more likely to have received a cephalosporin, macrolide, or a miscellaneous agent (eg, quinolone, tetracycline, or nitrofurantoin) (P =.001). CONCLUSIONS: Patients with a beta-lactam allergy had higher antibiotic costs and were more likely to receive a broader-spectrum antibiotic. Most patients with a reported allergy did not have a description of their reaction. Skin testing may be of use in detecting true beta-lactam allergies; however, further study is needed to determine its cost-effectiveness.

Asthma: an analysis of high-cost patients.

OBJECTIVE: To examine characteristics of asthma patients who accounted for 80 percent of national expenditures in 1994 dollars. STUDY DESIGN: Data were extracted from a comprehensive data source, the 1987 National Medical Expenditure Survey (NMES) of approximately 35,000 individuals. PATIENTS AND METHODS: Persons of interest were identified using any occurrence of the ICD-9 code 493 or subcategories. Population weighting factors were used to estimate the population in the United States who sought care for the treatment of asthma. Two groups were identified: a high-cost group, which accounted for 80 percent of the direct medical expenditures, and a low-cost group, which represented 20 percent of expenditures. All analyses were performed using SUDAAN software, which takes into account the complex sampling design used in NMES. RESULTS: Individuals who rated their health as poor or fair were more likely to be in the high-cost group, as compared with those who rated their health as good or excellent (p < .0009). Persons who reported having Medicare, other government, or private insurance were more likely to be in the high-cost group as compared to those with Medicaid and self-pay (p = .01). A person was more likely to be in the high-cost group if he or she used four or more different medications to treat asthma (p < .0001). CONCLUSIONS: Persons with asthma are more likely to have greater medical expenditures if they use four or more medications and have deteriorated health status. Managed care organizations and public programs may find these characteristics useful in targeting asthma prevention and management programs.

The relationship between drug therapy noncompliance and patient characteristics, health-related quality of life, and health care costs.

The objectives of this study were to determine the relationship between drug therapy compliance and risk of hospitalization and economic outcomes, and to identify potential indicators of compliance. We used computerized prescription records from 1,054 patients at high risk for drug-related problems. We calculated a compliance ratio for a 12-month period and correlated it with health care use, demographic variables, drug-related variables, and scores for health-related quality of life. Univariate results suggested that increased age (p=0.05), high number of chronic conditions (p<0.001), and high number of concurrent drugs (p<0.001) were positively correlated with compliance. That is, increased values for these variables were associated with better compliance. Using logistic regression, the odds of being noncompliant was 0.665 as the number of chronic conditions increased. Compliance was not a predictor of concurrent or future hospitalizations or mortality, nor was it a significant predictor of health care costs.

Types of interventions made by clinical pharmacists in the IMPROVE study. Impact of Managed Pharmaceutical Care on Resource Utilization and Outcomes in Veterans Affairs Medical Centers.

The purpose of this study was to describe and evaluate the activities and interventions provided by ambulatory care clinical pharmacists during the IMPROVE (Impact of Managed Pharmaceutical Care on Resource Utilization and Outcomes in Veterans Affairs Medical Centers) study. A total of 523 patients were randomized into the intervention arm at nine Veterans Affairs medical centers if they were considered to be at high risk for drug-related problems. Patients randomized to the control group had no interventions and they are not reported. Using a standard form, pharmacists were asked to document the length of visit, method of contact, medical conditions addressed, and drug-related problems addressed and resolved during each contact. Seventy-eight ambulatory care clinical pharmacists documented 1855 contacts over 12 months, an average of 3.54 +/- 2.31/patient. The length of visits was 15 minutes or more for 73% of contacts. In-person contacts accounted for 1421 visits (76.6%), with the remainder being telephone contacts. During each contact the average number of drug-related problems addressed and resolved were 1.64 +/- 1.16 and 1.14 +/- 0.98, respectively. More drug-related problems were addressed and resolved when visits were 15 minutes or longer (p=0.001) and when the contact was in person (p=0.001). These data may provide information to clinical pharmacists developing pharmacy-managed clinics for patients at high risk for drug-related problems. The information may be a benchmark for types of interventions that can be made, as well as the time commitments required to make them.

Assessing the structure and process for providing pharmaceutical care in Veterans Affairs medical centers.

The structure and process used in providing pharmaceutical care to ambulatory care patients at nine Veterans Affairs medical centers (VAMCs) were studied. Institutions participating in the IMPROVE (Impact of Managed Pharmaceutical Care on Resource Utilization and Outcomes in Veterans Affairs Medical Centers) study were selected. To assess the level of pharmaceutical care services provided to ambulatory care patients, 10 critical domains were identified. Six instruments with questions related to each domain were then designed, including a clinical pharmacist survey and an outpatient pharmacist survey. Each center was assessed through three surveys and an onsite visit. The investigators used both direct observation and a consensus approach to score the level of ambulatory care pharmaceutical services provided. The clinics in which IMPROVE study patients would be seen were run by pharmacists (33%), physicians (44%), and multidisciplinary teams (22%). Of the 51 clinical pharmacists surveyed, 23 (45%) had prescribing authority via protocols, 14 (28%) had unrestricted prescribing privileges, and 14 did not have prescribing authority. The sites varied greatly in referral patterns, methods of identifying patients, and whether patient visits were scheduled or on a walk-in basis. There was a strong correlation between observed activities by clinical pharmacists and their self-reports and between observed activities by outpatient pharmacists and their self-reports. Activities reported by clinical pharmacists were moderately but not significantly correlated with consensus scores, and activities reported by outpatient pharmacists were poorly correlated with consensus scores. The structure and process for providing pharmaceutical care to ambulatory care patients at VAMCs were evaluated with surveys, direct observation, and a consensus-based scoring system.