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.

Community adaptations to an impending food desert in rural Appalachia, USA.

INTRODUCTION: The United States Department of Agriculture (USDA) describes a food desert as an urban neighborhood or rural town without ready access to fresh, healthy, and affordable food. An estimated 2.3 million rural Americans live in food deserts. One goal of the USDA is to eliminate food deserts. However, at a time when some food deserts are being eliminated, hundreds of grocery stores are closing, causing other food deserts to arise. The literature is scarce on how a community adapts to an impending food desert. Alderson, West Virginia, USA (population 1184) rallied to face an impending food desert when the only grocery store in town closed in December 2014. This study investigated how this small rural community adapted to its oncoming food desert. METHODS: A community member survey was administered to 155 Alderson families (49%) to determine how the new food desert affected family food acquisition and storage behaviors. A restaurant survey was given to the town's four restaurants to determine how the food desert affected their businesses. Sales data for a new food hub (Green Grocer) was obtained to see if this new initiative offset the negative effects of the food desert. ANOVA and t-tests were used to compare group numerical data. Two group response rates were compared by testing the equality of two proportions. Categorical data were analyzed with the χ2 or frequency distribution analysis. Group averages are reported as mean ± standard error of the mean. Significance for all analyses was set at p<0.05. RESULTS: Even though 86% of the population shopped at the new Green Grocer, 77% did most of their shopping at a store at least 17.7 km (11 miles) from home. The number of long-distance monthly shopping trips made after the food desert (3.3±0.4) did not change significantly (p=0.16) from the number before the food desert (2.8±0.3). Price comparisons among the Green Grocer and three distant supermarkets showed a 30% savings by traveling to distant supermarkets. Frequency of monthly restaurant visits did not change after the emergence of the food desert (2.98±0.54 vs 3.05±0.51, p=0.85). However, restaurant patrons requested to buy fresh produce and dairy from the restaurants to use for their own home cooking. Food pantry use increased by 43%, with community members requesting more fresh produce, meat, and dairy. The food desert triggered a 21% increase in home gardening and an 11% increase in home food preservation. CONCLUSIONS: Opening a Green Grocer offset only some of the effects of the food desert, because community members use it as a convenience store to purchase fresh produce and dairy products that families may lack before their next long-distance trip to a supermarket. Alderson's low-income residents now rely more heavily on food pantry assistance, while a small number of other residents have started gardening and food preservation. The first factor governing food acquisition behavior in rural Appalachia is food pricing, with the proximity of food access coming in second. How to overcome these two major barriers to food security in the midst of current economics and marketing remains to be answered.

Steady-state pharmacokinetics of intravenous levetiracetam in neurocritical care patients.

STUDY OBJECTIVES: To characterize the steady-state pharmacokinetics of intravenous levetiracetam in neurocritical care patients requiring seizure prophylaxis after a neurologic injury and to determine which dosing regimens achieve serum concentrations within the recommended therapeutic range of 6-20 µg/ml. DESIGN. Prospective, open-label, steady-state pharmacokinetic study. SETTING: Neurocritical care unit in a tertiary care medical center. PATIENTS. Twelve adults (five men, seven women) admitted to the neurocritical care unit who required prophylactic anticonvulsant therapy after subarachnoid hemorrhage, subdural hematoma, or traumatic brain injury. INTERVENTION: Patients received an intravenous infusion of levetiracetam 500 mg over 15 minutes every 12 hours. MEASUREMENTS AND MAIN RESULTS: Serial blood samples were collected from all patients after a minimum of four doses of therapy. Serum levetiracetam concentrations were determined by ultraperformance liquid chromatography with tandem mass spectrometry detection, and pharmacokinetic data were analyzed by compartmental and noncompartmental methods. Monte Carlo simulations were performed for multiple levetiracetam dosing regimens to determine the probability of achieving a target trough concentration of 6 µg/ml or greater, 20 µg/ml or greater, and 6-20 µg/ml. The mean ± SD levetiracetam maximum serum concentration was 28.0 ± 8.0 µg/ml, minimum serum concentration 3.1 ± 1.8 µg/ml, half-life 5.2 ± 1.2 hours, systemic clearance 5.6 ± 1.8 L/hour, and volume of distribution at steady state 36.8 ± 6.3 L. Increasing the doses of levetiracetam increased the probability of achieving a target trough concentration of 6 µg/ml or greater but also increased the probability of achieving trough concentrations greater than 20 µg/ml. Levetiracetam doses of 1000 mg every 8 hours and 1500-2000 mg every 12 hours provided the highest probability of achieving a target trough concentration between 6 and 20 µg/ml. CONCLUSION: Compared with previously published results in healthy volunteers and adults in status epilepticus, levetiracetam systemic clearance was faster and the terminal elimination half-life was shorter in neurocritical care patients. Higher doses or more frequent dosing may be needed to achieve target trough concentrations of 6-20 µg/ml.