Drug prescribing for ambulatory patients 85 years of age and older.

Drug prescribing for ambulatory patients greater than or equal to 85 years of age was studied using data from the 1980 National Ambulatory Medical Care Survey (NAMCS) on office visits to physicians. NAMCS is a survey by the US National Center for Health Statistics, which collected information on office visits and extrapolated the results to the US population. Of the 575.7 million office visits by all ages, 6.8 million (1 per cent) were by persons greater than or equal to 85 years of age, and 64 per cent involved females. Ninety per cent of the total office visits of those greater than or equal to 85 years were with a physician who had seen them before; 94 per cent were with MDs as compared with DOs; 56 per cent were with general practitioners or internists; and 95 per cent had some type of follow-up planned. The most frequent duration of the office visit was 11-15 minutes (36 per cent). The most frequent diagnostic class was diseases of the circulatory system. The survey physicians were asked to list all drugs, new or already in use by the patient, that were ordered, administered, or prescribed during the visit. The authors converted the drug brand names to their nonproprietary or generic name component(s); each active ingredient of combination products was treated as a separate drug entity. All drug analyses used generic names. Thirty-two per cent of visits did not involve the use of any drug, 21 per cent involved one drug; 12 per cent, two drugs; and 16 per cent, three drugs. Cardiovascular-renal drugs were the most frequently mentioned. One-third of the visits involved the use of one or more drugs that have psychologic effects, either intended or as side effects. Three per cent of the office visits involved the use of two or more drugs that had the potential for clinically important interactions.

An evaluation of antihypertensive prescribing practices.

We evaluated the management of patients with hypertension (including drug prescribing) by US physicians, compared their prescribing to National Institutes of Health (NIH) guidelines, and compared the pharmacoeconomics of the prescribed antihypertensive drugs. A 1991 national US database, using physician-patient encounter forms, was our data source. Results showed that physicians generally met the NIH guidelines regarding diagnostic/screening services, patient counselling/education, antihypertensive drug prescribing and follow-up. Two areas should be the foci of continuing medical education for US physicians. Firstly, physicians need to be reminded that centrally acting alpha 2-agonists are optimally used as supplemental antihypertensive drugs rather than as initial agents, which is how some physicians utilised them. Secondly, if once-daily administration is used to promote patient compliance, physicians should be aware that, of the frequently prescribed first-line antihypertensive drugs, hydrochlorothiazide, chlorthalidone and atenolol presently have substantially less expensive once-daily dosage forms than other diuretics or beta-blockers, calcium antagonists or ACE inhibitors.

The Medicare Catastrophic Coverage Act of 1988: toward a research agenda for pharmacy.

Pharmacy administration investigators have been presented with a rare challenge and a once-in-a-lifetime window of opportunity. The research agenda in which all of us are vested has been raised to a level of unparalleled prominence. Funding is available in unprecedented amounts. Our background, education and interests provide us with an unusual and sure to be short-lived competitive advantage. It will not take long for traditional health services research groups to beg, borrow, or steal the expertise that we now possess. The pharmacy administration discipline must act quickly to stake a major claim in research efforts related to the drug program in MCCA. The issues of research related to the drug use process and the impact of pharmacy services are ours. We must be visionary, assertive, and ambitious in exploiting this opportunity to make a major contribution to the health services research needs of this nation.

Audit of digoxin prescribing in ambulatory patients.

Digoxin prescribing for ambulatory patients with uncomplicated congestive heart failure in normal sinus rhythm (UCHF) was evaluated. The audit was conducted at a hospital primary care clinic and was performed retrospectively over a recent 2-year period. The audit focused on the discontinuance of digoxin prescribing and the attendant monitoring necessary. There was 34 patients prescribed digoxin during the study period who were classified as UCHF. Of these, 23 (68%) met our a priori criteria for digoxin discontinuance. However, only three of the 23 were discontinued and none met the criteria for proper follow-up. With regard to monitoring, the average patient was seen once every 2 months, but in fewer than half of the visits the patient was assessed on basic subjective and objective parameters of CHF status and digoxin toxicity. These results are being used in an educational program for the clinic physicians who before the audit had perceived their care of digoxin patients to be optimal.

Strategy for increasing the demand for clinical pharmacists.

A strategy for increasing the demand for clinical pharmaceutical services in hospitals is described. The strategy consists of three steps: (1) Show that the overall quality of drug prescribing affects patient outcomes not only in a negative way but also in a positive manner; i.e., appropriate prescribing speeds recovery and minimizes the need for more expensive types of care; (2) show that the pharmacist can detect poor quality prescribing; and (3) show that after detecting poor quality prescribing, the clinical pharmacist can effectively intervene in the prescribing process to reduce inappropriate prescribing and improve patient outcomes.

Pharmacy practice in 2040.

Pharmacy practice 50 years in the future is discussed. The practice of pharmacy in 2040 will be influenced by many trends and issues, such as increasing cultural diversity, the aging population, evolving drug and information technology, rising drug costs, and increasing third-party coverage. Pharmacy may take one of two paths. In the first scenario, institutional and community practice would drift further apart, with community pharmacy becoming more involved with retailing than with health care. In the second scenario, all pharmacists would become a vital component of an integrated, patient-centered system of health care; pharmacists, like physicians, would be salaried professionals, paid for by health-care programs financed through health insurance. The difference between the two scenarios is the degree to which pharmacists actively participate in their creation: The first will happen if pharmacists do not take action; the second will require a considerable amount of work. If pharmacists wish to see an active system of patient-centered pharmaceutical care in 2040, they must begin to create it now, regardless of their practice setting. Pharmacists must work to create a future in which they are an integral part of the health-care system.