A pilot study evaluating alternative approaches of academic detailing in rural family practice clinics.

BACKGROUND: Academic detailing is an interactive, convenient, and user-friendly approach to delivering non-commercial education to healthcare clinicians. While evidence suggests academic detailing is associated with improvements in prescribing behavior, uncertainty exists about generalizability and scalability in diverse settings. Our study evaluates different models of delivering academic detailing in a rural family medicine setting. METHODS: We conducted a pilot project to assess the feasibility, effectiveness, and satisfaction with academic detailing delivered face-to-face as compared to a modified approach using distance-learning technology. The recipients were four family medicine clinics within the Oregon Rural Practice-based Research Network (ORPRN). Two clinics were allocated to receive face-to-face detailing and two received outreach through video conferencing or asynchronous web-based outreach. Surveys at midpoint and completion were used to assess effectiveness and satisfaction. RESULTS: Each clinic received four outreach visits over an eight month period. Topics included treatment-resistant depression, management of atypical antipsychotics, drugs for insomnia, and benzodiazepine tapering. Overall, 90% of participating clinicians were satisfied with the program. Respondents who received in person detailing reported a higher likelihood of changing their behavior compared to respondents in the distance detailing group for five of seven content areas. While 90%-100% of respondents indicated they would continue to participate if the program were continued, the likelihood of participation declined if only distance approaches were offered. CONCLUSIONS: We found strong support and satisfaction for the program among participating clinicians. Participants favored in-person approaches to distance interactions. Future efforts will be directed at quantitative methods for evaluating the economic and clinical effectiveness of detailing in rural family practice settings.

Adverse effects of antipsychotic medications.

The use of antipsychotic medications entails a difficult trade-off between the benefit of alleviating psychotic symptoms and the risk of troubling, sometimes life-shortening adverse effects. There is more variability among specific antipsychotic medications than there is between the first- and second-generation antipsychotic classes. The newer second-generation antipsychotics, especially clozapine and olanzapine, generally tend to cause more problems relating to metabolic syndrome, such as obesity and type 2 diabetes mellitus. Also, as a class, the older first-generation antipsychotics are more likely to be associated with movement disorders, but this is primarily true of medications that bind tightly to dopaminergic neuroreceptors, such as haloperidol, and less true of medications that bind weakly, such as chlorpromazine. Anticholinergic effects are especially prominent with weaker-binding first-generation antipsychotics, as well as with the second-generation antipsychotic clozapine. All antipsychotic medications are associated with an increased likelihood of sedation, sexual dysfunction, postural hypotension, cardiac arrhythmia, and sudden cardiac death. Primary care physicians should understand the individual adverse effect profiles of these medications. They should be vigilant for the occurrence of adverse effects, be willing to adjust or change medications as needed (or work with psychiatric colleagues to do so), and be prepared to treat any resulting medical sequelae.

Preparing to implement medication algorithms: staff perspectives and system infrastructure.

To assess the readiness of mental health facilities in Oregon to implement medication algorithms using the Medication Management Approaches in Psychiatry toolkit (MedMAP) developed by the Substance Abuse and Mental Health Services Administration (SAMHSA), researchers conducted interviews with 68 clinical and administrative employees of four inpatient and four outpatient mental health facilities in Oregon. Respondents had generally positive opinions about the algorithms, but they also expressed many concerns about logistics and implementation, chiefly related to medication selection and expected restrictions on choices for prescribing providers and patients. In implementing medication algorithms, it may be beneficial to assess staff perspectives as well as the capabilities of the program's infrastructure. The extent to which staff concerns, values, and needs are anticipated and promptly and responsively addressed is likely have a major influence on successful implementation.

Patterns of atypical antipsychotic subtherapeutic dosing among Oregon Medicaid patients.

OBJECTIVE: To examine a cohort of Medicaid patients with new prescriptions for atypical antipsychotic medication to determine the prevalence of subtherapeutic atypical antipsychotic medication use and to identify patient and prescribing provider characteristics associated with occurrence of subtherapeutic use. METHOD: This observational cohort study examined Medicaid administrative claims data for patients aged 20 to 64 years with a new prescription for an atypical antipsychotic medication (clozapine, olanzapine, quetiapine, risperidone, ziprasidone) between January 1, 2004, and December 31, 2004. Patient diagnostic information was identified using the International Classification of Diseases, Ninth Revision, Clinical Modification codes on submitted medical claims. Patient characteristics, prescribing provider characteristics, length of therapy, and dosing were examined. A logistic regression assessed the probability of subtherapeutic dosing. RESULTS: Among 830 individuals in our sample who began treatment with an atypical antipsychotic, only 15% had a documented diagnosis of schizophrenia, subtherapeutic dosing was common (up to 86% of patients taking quetiapine), and 40% continued less than 30 days with the index prescription. A logistic model indicated that a general practitioner as prescribing provider, length of therapy equal to or less than 30 days, and prescription of quetiapine were significantly associated with a subtherapeutic dose (p < .001, p = .028, and p < .001, respectively). CONCLUSIONS: These results suggest that there is extensive use of expensive atypical antipsychotic medications for off-label purposes such as sedation or for other practice patterns that should be explored further. Approaches that minimize off-label atypical antipsychotic use could be of considerable value to Medicaid programs. In addition, these findings support the need for the introduction or increased use of utilization monitoring and the implementation of medication practice guidelines as appropriate decision support for prescribing providers.

Initial results of the use of prescription order change forms to achieve dose form optimization (consolidation and tablet splitting) of SSRI antidepressants in a state Medicaid program.

BACKGROUND: One method to reduce drug costs is to promote dose form optimization strategies that take advantage of the flat pricing of some drugs, i.e., the same or nearly the same price for a 100 mg tablet and a 50 mg tablet of the same drug. Dose form optimization includes tablet splitting; taking half of a higher-strength tablet; and dose form consolidation, using 1 higher-strength tablet instead of 2 lower-strength tablets. Dose form optimization can reduce the direct cost of therapy by up to 50% while continuing the same daily dose of the same drug molecule. OBJECTIVE: To determine if voluntary prescription change forms for antidepressant drugs could induce dosing changes and reduce the cost of antidepressant therapy in a Medicaid population. METHODS: Specific regimens of 4 selective serotonin reuptake inhibitors (SSRIs)- citalopram, escitalopram, paroxetine, and sertraline- were identified for conversion to half tablets or dose optimization. Change forms, which served as valid prescriptions, were faxed to Oregon prescribers in October 2004. The results from both the returned forms and subsequent drug claims data were evaluated using a segmented linear regression. Citalopram claims were excluded from the cost analysis because the drug became available in generic form in October 2004. RESULTS: A total of 1,582 change forms were sent to 556 unique prescribers; 9.2% of the change forms were for dose consolidation and 90.8% were for tablet splitting. Of the 1,118 change forms (70.7%) that were returned, 956 (60.4% of those sent and 85.5% of those returned) authorized a prescription change to a lower-cost dose regimen. The average drug cost per day declined by 14.2%, from Dollars 2.26 to Dollars 1.94 in the intervention group, versus a 1.6% increase, from Dollars 2.52 to Dollars 2.56, in the group without dose consolidation or tablet splitting of the 3 SSRIs (sertraline, escitalopram, and immediate-release paroxetine). Total drug cost for the 3 SSRIs declined by 35.6%, from Dollars 333,567 to Dollars 214,794, as a result of a 24.8% decline in the total days of SSRI drug therapy and the 14.2% decline in average SSRI drug cost per day. The estimated monthly cost avoidance from this intervention, based on pharmacy claims data, was approximately Dollars 35,285, about 2% of the entire spending on SSRI drugs each month, or about Dollars 0.09 per member per month. Program administration costs, excluding costs incurred by prescribers and pharmacy providers, were about 2% of SSRI drug cost savings. CONCLUSIONS: Voluntary prescription change forms appear to be an effective and well-accepted tool for obtaining dose form optimization through dose form consolidation and tablet splitting, resulting in reduction in the direct costs of SSRI antidepressant drug therapy with minimal additional program administration costs.

Gabapentin use in a managed medicaid population.

OBJECTIVE: The use of gabapentin, an antiepileptic agent, in a primary care setting was evaluated to determine (a) the conditions being treated, (b) specialties of the prescribers, (c) dose ranges, and (d) the extent of documentation and follow-up. METHODS: A retrospective review of both claims data and patient charts was performed by a clinical pharmacist. Patients were identified from CareOregon and Oregon Medicaid fee-for-service drug claim databases. All patients were recipients of the Oregon Medicaid program known as the Oregon Health Plan (OHP) and were enrolled members of CareOregon, a contracted OHP managed care organization that primarily serves Medicaid recipients. All patients received care at one of four Oregon Health and Science University primary care clinics. RESULTS: Of the 105 patients studied, 95% received gabapentin for off-label diagnoses. Chronic pain and mental disorders were the diagnoses associated with the majority of prescriptions for gabapentin. Dose and dose intervals varied greatly. Very few patients (12%) had a documented efficacious response to gabapentin therapy. Of the patients started on gabapentin, 40% of patients had no documented follow-up. CONCLUSIONS: Almost all patients in this sample from the Medicaid managed population received gabapentin for off-label indications. Evidence from clinical trials does not support the use of gabapentin for many of the conditions treated with gabapentin in this study. Most patients did not appear to benefit from gabapentin therapy.