The economic realities of rural pharmacy practice.

Rural pharmacy practice is characterized by difficulties in recruiting and retaining pharmacists, demanding workloads and financial pressures that exceed those felt by pharmacies in urban areas. There is little optimism that these harsh realities will soon ease, given the shortage of pharmacists, high drug costs, and leverage by third-party payers. These realities should create concern among policy-makers for the economic viability of rural pharmacies and for the continued ability of pharmacists to provide health care services to residents of rural and frontier communities.

Pharmacy-managed protocol for warfarin use in orthopedic surgery patients.

A pharmacy-managed protocol for warfarin use in orthopedic surgery patients was studied. In 1990 a protocol designed to accommodate either protocol- or physician-determined dosing of warfarin for orthopedic antithrombotic prophylaxis (OAP) was implemented at a community hospital. A "protocol" group consisting of patients treated entirely under the protocol-determined dosing option was prospectively identified over a two-year period. A "physician" group consisting of patients treated by physicians in the 10 months immediately preceding implementation of the protocol was also identified. The ability of the protocol to achieve laboratory-test and clinical goals was assessed by comparing the two groups. The proportion of patients who received OAP increased from 89% for the physician group to 98% for the protocol group. Mean prothrombin times (PTs) were significantly higher in the protocol group only on postoperative day 2; 66% of all PTs beyond post-operative day 1 in the protocol group were within the targeted range, which reflected an International Normalized Ratio of 1.6-3.2. The frequencies of clinically apparent postoperative thrombotic events and bleeding episodes were low in each group and comparable to literature values. Analysis of protocol-group patients with PTs of > 20 seconds indicated that lower weight, female sex, and blood loss during surgery were associated with an elevated PT. The protocol was revised to provide for a lower initial warfarin dose in elderly women. A pharmacy-managed protocol for dosing warfarin achieved therapeutic goals and promoted nearly universal use of OAP in patients undergoing high-risk orthopedic surgery.

Diffusion of innovation II: Formulary acceptance rates of new drugs in teaching and non-teaching British Columbia hospitals--a drug development perspective.

Diffusion theory was used to examine differences in adoption rates of new drugs by British Columbia teaching and non-teaching hospitals. Surveys were mailed in September 1990 to 41 hospital pharmacies (response rate = 88%), requesting hospital pharmacy directors to provide formulary inclusion dates of 29 study drugs marketed between July 1987 and March 1990. Of the 36 initial responses, 31 were suitable for further analysis and these were surveyed again in April 1993 (response rate = 100%) as to the formulary status of drugs not initially approved. The second survey ensured that all study drugs would have at least 36 months on the Canadian market when determining formulary acceptance times. Of the 29 study drugs, six were not approved for use in any of the 31 study hospitals. The six teaching hospitals had a median formulary approval time of 8.0 months compared to 12.8 months in the 25 non-teaching hospitals for the 23 study drugs. Although 21 of 23 study drugs were approved for use earlier in teaching hospitals than non-teaching hospitals, only alfentanil was found to be adopted significantly earlier (U = 11, n1 = 5, n2 = 19, alpha = 0.05). Variations in formulary approval times for new drugs have a bearing on patient care, Pharmacy and Therapeutics Committees, hospital budgets, and pharmaceutical firm revenues.

Diffusion of innovation I: Formulary acceptance rates of new drugs in teaching and non-teaching British Columbia hospitals--a hospital pharmacy perspective.

Lag times in the diffusion of new drugs in the hospital setting have both patient care and pharmaceutical industry implications. This two-part series uses diffusion theory to examine differences in the adoption rates of new drugs in British Columbia teaching and non-teaching hospitals. Formulary addition of a new drug by a hospital's Pharmacy and Therapeutics Committee was considered the adoption indicator. Time for adoption was defined as the difference between a drug's Canadian market approval date and the date of formulary addition. Surveys were mailed in September 1990 to 41 hospital pharmacies (response rate = 88%), asking respondents to provide formulary inclusion dates of 29 drugs marketed between July 1987 and March 1990. A significant difference (Mann-Whitney U Test, p < 0.0358) in median adoption time was observed between the six teaching and 25 non-teaching study hospitals, with the former adopting a new drug in 7.5 months versus the latter adopting a new drug in 12.1 months.

Community pharmacists' participation in health education and disease prevention activities.

Community pharmacists are faced with many opportunities to participate in health education and disease prevention activities. This study sought to determine the extent to which community pharmacists in British Columbia participate in such activities. A mail questionnaire was distributed to a systematic, stratified sample of 625 community pharmacists in B.C. (response rate = 83.6%). A five-point Likert-type scale was used to examine the frequencies of pharmacist involvement in 33 different health education/disease prevention activities. Results of the study indicate that pharmacists most frequently participate in health education/disease-preventing activities directly related to the dispensing or selling of medications. Activities exhibiting the lowest participation among pharmacists included speaking to community groups on health-related matters, participating in disease screening programs, querying clients on their level of occupational stress, counselling clients on AIDS prevention, and querying clients on their smoking status.

Obtaining a critical care pharmacist position: a marketing case study.

Marketing theory is used to explain how Pharmacy Department managers at a Vancouver-area hospital secured a new ICU pharmacist position in a period of severe fiscal constraint. Market segmentation, target marketing and pull marketing strategy were combined to obtain support for the new position. Improved drug information services for ICU nurses were promoted to Nursing Administration and enhanced pharmacotherapy monitoring was promoted to the two critical care physicians primarily responsible for patient care in the ICU. These physicians and Nursing Administration voiced their support for the new position to the V.P. of Nursing (the functional officer for Pharmacy), who then promoted the new position to Hospital Administration. A half-time DUR commitment by the ICU pharmacist was offered to Hospital Administration, expanding this already successful service and guaranteeing cost recovery for the new position. Hospital Administration approved the new ICU clinical pharmacist position in a budget which saw other hospital departments lose several positions.

Cost savings from hetastarch use in place of albumin on a cardiothoracic surgery service.

The use of hetastarch in 38 cardiothoracic surgery patients was monitored prospectively to determine patient parameters that influence physicians' prescribing practices. Potential cost savings from substituting hetastarch for albumin were calculated and use of hetastarch, following introduction to the hospital, was monitored. Data were statistically analyzed, and no correlation was seen among operative procedure, type of admission (transfer or direct admission), or patient age. During the 2-month study period, $800 was saved on the cardiothoracic surgery unit by substituting hetastarch for 5% albumin. An additional $1,600 could have been saved if optimal amounts of hetastarch had been used. Substitution of hetastarch for 5% albumin on just one intensive care unit in this 283-bed hospital is projected to elicit annual cost savings of $14,000.

Comparison of consumer-oriented books on medications.

Consumers increasingly want to be informed about the processes involved in their own health care. Health professionals may be called upon to recommend appropriate consumer-oriented sources of information. To assist the health professional in making a rational recommendation, 15 currently available consumer-oriented books on prescription medications were compared with respect to readability, number of drugs covered, completeness of drug monograph information, price, and other factors. Mean readability scores, reported as a reading grade level, ranged from 9.2 to 14.3. The number of drugs covered by these books ranged from 135 to 1,200. Monograph completeness scores were assigned by determining the percentage of information from a standard reference's drug monograph covered in each book. The lowest percentage completeness score was 21.4%, while the highest was 76.7%. Prices for the books ranged from $2.50 to $19.95. Regardless of the relative priorities placed on these factors, a consumer or health professional may use the objective and descriptive assessments of this study to make an informed decision when choosing among consumer-oriented sources of medication information.