Financial stress is associated with reduced treatment adherence in HIV-infected adults in a resource-rich setting.

OBJECTIVES: Financial stress has been identified as a barrier to antiretroviral adherence, but only in resource- limited settings. Almost half of HIV-infected Australian adults earn no regular income and, despite highly subsidised antiretroviral therapy and universal health care, 3% of HIV-infected Australians cease antiretroviral therapy each year. We studied the relationship between financial stress and treatment adherence in a resource-rich setting. METHODS: Out-patients attending the HIV clinic at St Vincent's Hospital between November 2010 and May 2011 were invited to complete an anonymous survey including questions relating to costs and adherence. RESULTS: Of 335 HIV-infected patients (95.8% male; mean age 52 years; hepatitis coinfection 9.2%), 65 patients (19.6%) stated that it was difficult or very difficult to meet pharmacy dispensing costs, 49 (14.6%) reported that they had delayed purchasing medication because of pharmacy costs, and 30 (9.0%) reported that they had ceased medication because of pharmacy costs. Of the 65 patients with difficulties meeting pharmacy costs, 19 (29.2%) had ceased medication vs. 11 (4.1%) of the remaining 270 patients (P < 0.0001). In addition, 19 patients (5.7%) also stated that it was difficult or very difficult to meet travel costs to the clinic. Treatment cessation and interruption were both independently associated with difficulty meeting both pharmacy and clinic travel costs. Only 4.9% had been asked if they were having difficulty paying for medication. CONCLUSIONS: These are the first data to show that pharmacy dispensing and clinic travel costs may affect treatment adherence in a resource-rich setting. Patients should be asked if financial stress is limiting their treatment adherence.

Cost-effectiveness of HIV nonoccupational post-exposure prophylaxis in Australia.

OBJECTIVE: The aim of the study was to determine the cost-effectiveness of HIV nonoccupational post-exposure prophylaxis (NPEP) in Australia. METHODS: A retrospective cost analysis of a population-based observational cohort of 1601 participants eligible for NPEP in Australia between 1998 and 2004 was carried out. We modelled NPEP treatment costs and combined them with effectiveness outcomes to calculate the cost per seroconversion avoided. We estimated the cost-utility of the programme, and sensitivity and threshold analysis was performed on key variables. RESULTS: The average NPEP cost per patient was A$1616, of which A$848 (52%) was for drugs, A$331 (21%) for consultations, A$225 (14%) for pathology and A$212 (13%) for other costs. The cost per seroconversion avoided in the cohort was A$1 647,476 in our base case analysis, and A$512,410 when transmission rates were set at their maximal values. The cost per quality-adjusted life-year (QALY) was between A$40,673 and A$176,772, depending on the risks of HIV transmission assumed. CONCLUSIONS: In our base case, NPEP was not a cost-effective intervention compared with the widely accepted Australian threshold of A$50,000 per QALY. It was only cost-effective after receptive unprotected anal intercourse exposure to an HIV-positive source. Although NPEP was a relatively well-targeted intervention in Australia, its cost-effectiveness could be improved by further targeting high-risk exposures.

A method for determining leakage of 133Xe gas from septum-sealed glass vials.

We have developed a method for determining the leakage of 133Xe gas from septum-sealed glass vials that are supplied for medical examinations. Twenty vials each originally containing 370 MBq of 133Xe and 20 vials each originally containing 740 MBq 133Xe were measured daily for 26 d. Retention of 133Xe within the vial was modeled as a first order process with a constant rate coefficient, lambdaT. The value of lambdaT was estimated for each vial using a regression analysis. The leakage rate, lambdaL, was then determined assuming that lambdaT = lambdaL + lambda(r) where lambda(r) represents the physical decay of 133Xe. Monte Carlo simulations were performed using uncertainties in the estimates of each vial to obtain the mean and tails of the distribution for the average leakage rate, lambdaL. The average leakage rate for the complete sample of vials was 0.00007 d(-1) with an upper, one-sided, 95% confidence limit of 0.0011 d(-1). Uncertainties in the published values of lambda(r) for 133Xe made a significant contribution to the uncertainties of the leakage rate for this sample of vials. The methods described can be applied to other situations where leakage of radioactive materials may be of concern.

Continuous-flow delivery of nitrous oxide and oxygen: a safe and cost-effective technique for inhalation analgesia and sedation of pediatric patients.

Nitrous oxide (N2O) safely and rapidly alleviates the pain and distress of minor procedures in the emergency department (ED). We have found self-administration in children does not consistently achieve acceptable analgesia and sedation. The equipment generally available for ED use is designed for adults and delivers 50% N2O through a demand valve that requires an inspiratory effort of -3 to -5 cm of water to activate gas flow. This is difficult for young children who are crying, have more shallow respirations than adults, or cannot follow instructions. In collaboration with the Departments of Anesthesiology, Dentistry, and Respiratory Therapy, we constructed a continuous-flow system for delivering N2O and oxygen (O2). The following is a description of the components, assembly, and use of a continuous-flow machine that safely and inexpensively delivers N2O and O2 to children.

Task analysis of home care pharmacy.

The demographics of home care pharmacists and the frequency and perceived importance of home care pharmacy tasks were studied. Two questionnaires were mailed in August 1994 to each of 1420 sites that provide home care pharmacy services. Home care pharmacists were asked to provide information on themselves and their companies and to rate 47 home care pharmacy tasks (administrative, clinical, distributive, and miscellaneous) on how often they are performed as part of the job and how essential they are for successful job performance. Of the 2840 surveys mailed to the 1420 sites, questionnaires for 87 sites were not deliverable, leaving an adjusted gross sample of 1333 sites. A total of 393 usable questionnaires were received from 326 sites (net site response rate 24.5%). Respondents tended to be male, have a B.S. degree only, and have more than six years' home care experience. The most commonly identified type of employer was an independent company. Some 34% of respondents said their company had only 1 site; another 33% stated more than 50 sites. Forty-three percent of locations had 2 pharmacist full-time equivalents. Distributive tasks had the highest frequency scores; clinical tasks were performed second most frequently. Distributive and clinical tasks also received high importance scores. The data suggests that, despite other demands on their time, home care pharmacists give considerable attention to tasks consistent with pharmaceutical care. A survey of home care pharmacists provided baseline information on demographics and the frequency and perceived importance of specific tasks.

Pharmacist's role in home i.v. therapy.

The pharmacist's role in home i.v. therapy is described, and its relationship to the Medicare Catastrophic Coverage Act is discussed. Congress, in enacting the catastrophic coverage act, has recognized the need for pharmaceutical services in the provision of home i.v. therapy. Pharmacists must recognize their responsibilities in providing these services. These responsibilities include ensuring the quality of drug therapy, monitoring patient progress, advocating cost-effective therapy, and communicating with local health-care providers. Pharmacists should also educate hospital administrators about the effects of the act, suggest how the hospital can best provide home i.v. therapy, assume responsibility for overseeing the home i.v. therapy process, and help ensure compliance with the interpretive regulations of the act. Other responsibilities of pharmacists include educating potential beneficiaries about the need to pay the coinsurance and premiums for catastrophic coverage and advocating home i.v. therapy as a reasonable alternative to hospitalization. Pharmacists should become familiar with the Standards for the Accreditation of Home Care adopted by the Joint Commission on Accreditation of Healthcare Organizations because these standards may be considered when the conditions for provider participation are established by the Department of Health and Human Services. The home i.v. therapy provision of the catastrophic coverage act presents challenges for pharmacists. Appropriate pharmacist involvement should help reduce costs and ensure optimal health care.

Controversial issues in home health care: a roundtable discussion.

Controversial issues in home health care (HHC) were discussed by a panel of four individuals involved in or knowledgeable about HHC. The panel addressed the following issues: reluctance of health professionals to participate in home care, challenges in providing HHC services, assigning responsibility for HHC services, reimbursement considerations in joint-venture arrangements, assuming fiscal responsibility for unreimbursed care, selecting HHC providers, defining patient rights, selecting drug products for home-care patients, competing with community pharmacists, circumvention of pharmacist input in preparation of solutions for home infusion, and the future of HHC. Hospital pharmacists who plan to become involved or are already involved in providing HHC services should become familiar with these controversial issues.

Comprehensive pharmaceutical services in the surgical suite and recovery room.

The operation of a pharmacy satellite located within the operating suite of a large university hospital is described. The satellite provides comprehensive services 24 hours a day, seven days a week to the staff of the operating room (OR), recovery room, and anesthesia department. Kits of anesthetic agents and other drugs used by the anesthetist and surgeon are prepared for each surgical procedure. The pharmacy staff also prepares i.v. admixtures, cardioplegic solutions, and specialized preparations as needed for surgery and provides drugs and i.v. admixture services to the recovery room for postoperative patients. Controlled substances are signed out to the anesthetist as needed in the particular kits and are issued as single doses upon request to the recovery room. All pharmacy charges to patients in the OR are done directly from the pharmacy satellite using a computer charging system. The decentralized pharmacy satellite has substantially reduced drug loss and waste, improved drug delivery to patients, increased revenue for the institution, reduced drug inventory, improved controlled-drug distribution and accountability, improved clinical services, and eased the nursing workload by reassigning drug-related responsibilities to the pharmacy department. The OR pharmacy satellite is a viable cost-effective operation.

Evaluating alternatives for providing home health-care services.

Alternatives for providing home health-care services (HHC) are discussed. An institution may provide HHC services for a variety of reasons including economic incentives, physician requests, consumer demands, and a desire to provide continuity of care. In planning an HHC program, data should be collected to provide a reliable estimate for potential HHC referrals. Demographic and reimbursement information on potential referrals should also be collected. Six basic HHC functions--patients screening and selection, patient training, product compounding, supply distribution, clinical management, and reimbursement--are described. The level of institutional participation in each of these functions is determined by the number of patients who require the services, the availability of resources, and the interest and expertise of the hospital staff. Alternatives for carrying out these responsibilities are discussed. The process for screening potential HHC providers is described. The value of competitive bidding for HHC services is emphasized, and specific data for the bid request and contract development are presented. Hospitals can provide HHC services through a variety of mechanisms ranging from the total delegation of HHC responsibilities to an external organization to the independent assumption of all HHC functions by the hospital. Hospital pharmacists can play a leadership role in HHC program development.

Challenges in purchasing and inventory control.

In this concluding installment in a multipart series, issues that should be considered in the improvement of hospital pharmacy purchasing and inventory control systems are presented. Pharmacists must be aware of possible variation in bioavailability among different formulations of the same drug and evaluate new vendors critically. Hospital pharmacists and industry representatives should strive for a cooperative relationship by fostering ongoing dialogue. Pharmacists must continue to demand competitive bid prices on generically equivalent products of equal quality. Firm contact prices cannot be expected if product use estimates are unreliable. It is unethical to encourage additional price reductions on competitive products after a formal bid has been received. Institutions should limit their participation to one group purchasing organization or wholesaler for the competitive bid process. Inventory management through methods such as ABC analysis, economic-order quantities, calculated optimum reorder points, and other quantitative measurements should become commonplace. The use of data processing systems and devices can enable pharmacists to become more proficient at pharmaceutical purchasing and inventory control. The acquisition and distribution of pharmaceuticals in health-care institutions require good management to capture the opportunities in this area for pharmacy to contribute to fiscally sound health care.

The role of the pharmacist in home health care.

Home infusion services, a new facet of home health care (HHC) delivery, have created many new opportunities for hospital pharmacists to participate more actively in patient care. These opportunities can create new roles for the pharmacist as an educator, clinician, and administrator. Early efforts must be made to educate hospital administrators, physicians, and other allied health personnel regarding the advantages and disadvantages of providing HHC--from the perspective of both patients and institutions. The pharmacist can also collect data to assist in determining the extent to which the institution should participate in HHC delivery, and should coordinate the hospital's efforts to initiate home infusion services. Pharmacists should play an active role in screening, selecting, and training patients for HHC before discharge. The input of pharmacists in drug product selection and assistance in product compounding can ensure optimal patient outcomes and minimize costs. Clinical monitoring activities conducted by the pharmacist can include telephone interviews with patients at home and assessment of clinical progress during scheduled return visits to the clinic.

Bid solicitation and contract negotiation.

The process of soliciting bid prices for drug products and of negotiating contracts with pharmaceutical vendors is reviewed. The primary purpose of bid purchasing is to obtain drugs at the lowest price and to have these prices remain fixed for a predetermined period of time. A successful bid-purchasing process depends on the institution's implementation of a formulary brand-standardization policy, prior identification of acceptable vendors and drug products, and establishment of criteria for evaluating drugs under a bid-purchasing system. Specific information to be included in the invitation to bid and useful data other than drug prices that may be solicited from vendors are outlined. Manual and computerized systems for organizing bid-request data are described. Bid evaluations should maintain the confidentiality of bid and contract prices. Selection of winning bids is based on lowest price or, in cases where prices are identical, on selected vendor characteristics or services. Negotiation of unacceptable bid prices should be conducted with a thorough knowledge of the needs and goals of the institution and the vendor. Procedures for establishing contracts and the timing of various phases of the bid process are discussed. An optimal bid-purchasing system is achieved only when the system is carefully planned and designed and when each prospective vendor is given an equal opportunity to establish a contractual relationship with the institution.

Purchasing and inventory control--past, present, and future.

Factors that have affected hospital pharmacy purchasing and inventory control functions are discussed, and future trends are suggested. The concepts of the pharmacy and therapeutics committee and the hospital formulary system stemmed from early hospital pharmacy practice standards that were promulgated about the time drug products began to proliferate. Brand standardization, restricted drug-use policies, and selection of therapeutic alternates are among the approaches P & T committees have devised to hold down hospital drug costs; these efforts will expand. Brand-comparison advertising, use of various incentives to physicians and pharmacists, premarketing publicity about new products, improved product packaging, and support of research studies are among the promotional tactics pharmaceutical manufacturers have employed and are likely to expand. Government legislation and regulations that have had the effect of increasing the cost of drugs may be modified. Hospital pharmacists should monitor developments such as these to prepare themselves for the challenges in their purchasing and inventory control responsibilities.