Global prevalence of cerebral palsy: A systematic analysis.

AIM: To determine trends and current estimates in regional and global prevalence of cerebral palsy (CP). METHOD: A systematic analysis of data from participating CP registers/surveillance systems and population-based prevalence studies (from birth year 1995) was performed. Quality and risk of bias were assessed for both data sources. Analyses were conducted for pre-/perinatal, postnatal, neonatal, and overall CP. For each region, trends were statistically classified as increasing, decreasing, heterogeneous, or no change, and most recent prevalence estimates with 95% confidence intervals (CI) were calculated. Meta-analyses were conducted to determine current birth prevalence estimates (from birth year 2010). RESULTS: Forty-one regions from 27 countries across five continents were represented. Pre-/perinatal birth prevalence declined significantly across Europe and Australia (11 out of 14 regions), with no change in postneonatal CP. From the limited but increasing data available from regions in low- and middle-income countries (LMICs), birth prevalence for pre-/perinatal CP was as high as 3.4 per 1000 (95% CI 3.0-3.9) live births. Following meta-analyses, birth prevalence for pre-/perinatal CP in regions from high-income countries (HICs) was 1.5 per 1000 (95% CI 1.4-1.6) live births, and 1.6 per 1000 (95% CI 1.5-1.7) live births when postneonatal CP was included. INTERPRETATION: The birth prevalence estimate of CP in HICs declined to 1.6 per 1000 live births. Data available from LMICs indicated markedly higher birth prevalence. WHAT THIS PAPER ADDS: • Birth prevalence of pre-/perinatal cerebral palsy (CP) in high-income countries (HICs) is decreasing. • Current overall CP birth prevalence for HICs is 1.6 per 1000 live births. • Trends in low- and middle-income countries (LMICs) cannot currently be measured. • Current birth prevalence in LMICs is markedly higher than in HICs. • Active surveillance of CP helps to assess the impact of medical advancements and social/economic development. • Population-based data on prevalence and trends of CP are critical to inform policy.

Request for an Andexxa Value Analysis.

This perspective is a formal request to the American College of Cardiology and American Heart Association (ACC/AHA) to perform a value analysis on andexanet (Andexxa) similar to what was completed for the PCSK9 inhibitors in the 2018 ACC/AHA Blood Cholesterol guidelines. Based on the safety and efficacy concerns of andexanet alfa, a value statement in and or as an addendum to society guidelines is vital considering the high cost of therapy. In this era of ever-increasing health care costs, every clinician, health system, national society, insurer, and pharmaceutical company should work to be good stewards of our society's resources.

Operational and Clinical Strategies to Address Drug Cost Containment in the Acute Care Setting.

OBJECTIVE: To provide clinical and operational strategies to generate drug cost savings in the hospital setting. METHODS: A search of the PubMed database was performed with no time limit through July 2016. All original prospective and retrospective studies, peer-reviewed guidelines, consensus statements, review articles, and accompanying references were evaluated for inclusion. Only articles published in the English language were included. MAIN RESULTS: Investigators reviewed 937 abstracts. The review of the literature showed that acute care hospitals are under increasing financial pressures, and the pharmacy is often responsible for opportunities to manage drug costs. The literature also indicated that cost-containment strategies in the acute care setting range from pharmacy-directed activities to initiatives requiring interdisciplinary collaboration and strategic planning. Hospital pharmacies should consider establishing an interdisciplinary team that is responsible for systematically reviewing drug cost implications and leading any initiatives that are deemed necessary. Acute care settings can use various operational and clinical strategies to lower their expenditures on high-cost drugs. Operational strategies include various activities that pharmacy staff implement related to contracting, purchasing, and inventory management. Clinical strategies utilize clinical pharmacists working with interdisciplinary teams to develop and maintain a formulary, implement established-use criteria for select drugs, use dose optimization, and implement other clinical tactics aimed at cost containment. After initiatives are implemented, assessing the outcomes of the initiatives is important to determine how successful they were at lowering costs safely and effectively. CONCLUSION: Acute care hospitals can use various operational and clinical strategies to lower overall drug costs. A systematic stepwise approach is recommended to ensure relevant drugs are regularly reviewed and addressed as needed.

Blood pressure level attainment among patients with coronary artery disease and uncontrolled blood pressure.

STUDY OBJECTIVES: To determine the proportion of patients with coronary artery disease (CAD) and uncontrolled blood pressure who attained a blood pressure of less than 130/80 mm Hg, and to compare patient- and health system- specific characteristics and identify factors independently associated with attaining this blood pressure level. DESIGN: Retrospective, longitudinal, cohort study. SETTING: Health maintenance organization. PATIENTS: A cohort of 1380 patients (14%) who had uncontrolled blood pressure out of 9785 adults with established CAD enrolled in the Clinical Pharmacy Cardiac Risk Service. MEASUREMENTS AND MAIN RESULTS: Uncontrolled hypertension was defined as a mean of two consecutive blood pressure readings of 140/90 mm Hg or higher in 2006 or 2007, most proximal to December 31, 2007 (baseline). The cohort was followed from January 1, 2008-June 30, 2009 (follow-up). The follow-up blood pressure level was the mean of the last two consecutive blood pressure readings most proximal to June 30, 2009. Of the 1380 patients, 34.9% (482 patients), 34.0% (469), and 31.1% (429) attained a blood pressure below 130/80, 130/80-139/89, and 140/90 mm Hg or higher, respectively, at follow-up. Significantly more patients in the less than 130/80 mm Hg group were male, had Medicare insurance, had lower baseline systolic and/or diastolic blood pressures, and had a higher Chronic Disease Score compared with the other groups. For every additional clinic visit, there was a 3% increased likelihood of attaining a blood pressure below 130/80 mm Hg (adjusted odds ratio [OR] 1.03, 95% confidence interval [CI] 1.01-1.04). Patients experiencing a cardiac event during the follow-up period were approximately twice as likely to attain a blood pressure below 130/80 mm Hg (OR 1.97, 95% CI 1.04-3.77) compared with those who did not have a subsequent event. CONCLUSION: Despite systematic and aggressive treatment of blood pressure in patients with CAD and uncontrolled blood pressure, a minority of patients attained a blood pressure of less than 130/80 mm Hg. Considering that higher utilization of the health care system was associated with reaching this blood pressure level and that a similar number of therapeutic interventions in the groups resulted in variable success for blood pressure lowering, attaining a blood pressure level of less than 130/80 mm Hg may be difficult for some patients with CAD.

The impact of continuing professional development versus traditional continuing pharmacy education on pharmacy practice.

BACKGROUND: The Institute of Medicine states that the new vision for continuing education (CE) for health-care professionals will be based on continuing professional development (CPD); however, information on the utility of CPD is lacking. OBJECTIVE: To assess the effect of CPD, compared with that of traditional continuing pharmacy education (CPE), on perceptions of factors related to pharmacy practice. METHODS: This 10-month, nonblinded, randomized controlled study recruited licensed pharmacists employed at a health maintenance organization (HMO). After completing a basic CPD course, participants were randomized to the intervention or control group. The control group was instructed to continue with traditional CPE. The intervention group participants completed 3 CPD workshops and were instructed to utilize the CPD approach for their learning needs. At baseline and follow-up, all participants completed a study questionnaire on perceptions of their pharmacy practices. The outcome measures were comparisons on follow-up and changes from baseline to follow-up in responses to the study questionnaire. RESULTS: One hundred pharmacists were enrolled. The intervention (n = 44, 7 lost to follow-up) and control (n = 47, 2 lost to follow-up) groups were similar at baseline. At follow-up, a higher percentage of intervention participants reported that they had better interactions with other health-care providers (always/frequently 32% vs 6%, respectively) and initiated practice/work changes (always/frequently 21% vs 0%, respectively) (both p < 0.01) as a result of their education activities. Compared with control participants at follow-up, intervention participants reported that their education activities improved patient care changes (46% vs 23%), professional knowledge (34% vs 6%), skills (48% vs 17%), and attitudes/values (43% to 11%) (all p < 0.05). However, intervention participants reported more often that time was a barrier to completing education activities (75% vs 32%, p < 0.001). CONCLUSIONS: Pharmacists who participated in CPD reported more often that their perceptions of various aspects of their pharmacy practice improved as a result of their education activities compared with pharmacists who participated in traditional CPE.

A model for continuing pharmacy education.

OBJECTIVE: To develop and implement a continuing pharmacy education (CPE) program at Kaiser Permanente Colorado (KPCO) DESIGN: To address the continuing education needs of its diverse pharmacy staff, an internal continuing pharmacy education (CPE) program was developed. The pharmacy department became an accredited provider by the Accreditation Council for Pharmacy Education (ACPE). Live, interactive, and evidence-based CPE programs, presented by highly qualified internal staff members, utilized videoconferencing and a Web-based learning management system. Cross-accreditation of medical and pharmacy educational programs was offered to KPCO staff members. ASSESSMENT: Annual needs assessments were conducted to ensure the provision of relevant educational topics and to assess learning needs. To demonstrate outcomes of the CPE programs, 2 methods were utilized: objective effectiveness assessment and knowledge acquisition assessment. This program met the objectives for CPE activities a large majority of the time (usually over 90%), demonstrated statistically significant (p < 0.05) improvement in knowledge from before to after the CPE activity in 11 of 13 questions asked, and minimized the cost to acquire CPE credit for both the pharmacy department and its staff members. CONCLUSION: The KPCO continuing pharmacy education program has developed a high quality and cost-favorable system that has resulted in significant improvements in attendee knowledge.

Angiotensin-converting enzyme inhibitor therapy for coronary artery disease and diabetes mellitus.

OBJECTIVES: To use a population management strategy to increase the proportion of patients with coronary artery disease (CAD) and diabetes receiving target-dose angiotensin-converting enzyme (ACE) inhibitor therapy and to assess the safety and tolerability of this initiative. STUDY DESIGN: Prospective cohort. METHODS: Patients were eligible for enrollment if they were not receiving target-dose ACE inhibitor therapy. Clinical pharmacy specialists were responsible for initiation, titration, and appropriate follow-up of ACE inhibitor therapy. RESULTS: A total of 453 subjects were enrolled. Their mean age was 67.9 years and 77% were male. At baseline, 30.9% (n = 140) of eligible patients were on no ACE inhibitor therapy and no patients were at the target dose. The mean systolic blood pressure, serum creatinine, and serum potassium values were 128.0 mm Hg, 1.0 mg/dL, and 4.4 mEq/dL, respectively. At follow-up, 8.2% (n = 37; P < .001) were on no ACE inhibitor therapy and 68.7% (n = 311; P < .001) of patients had achieved the target dose. From baseline to follow-up, mean systolic blood pressure decreased 4.4 mm Hg (P < .001). Changes in serum potassium or creatinine were not clinically significant. Of the 142 subjects unable to achieve the target dose, 31 experienced hypotension, 29 did not have the dose increased because of the potential for hypotension, and 23 experienced cough. CONCLUSION: A population management approach to increasing the proportion of patients with CAD and diabetes who receive target-dose ACE inhibitor therapy was effective and safe.