Cost-effectiveness of regional poison control centers.

BACKGROUND: Poison exposures are a significant public health concern. Despite the impact that regional poison control centers have on reducing morbidity and mortality associated with poison exposures, they are facing a serious financial crisis today resulting in an increased emphasis on their economic justification. METHODS: Using decision-analysis techniques, the cost-effectiveness of the treatment of poison exposures with the services of a regional poison control center compared with treatment without access to any poison control center was evaluated. The relative cost-effectiveness was modeled based on 2 outcomes (morbidity and mortality) for each of 4 typical poison exposures. Additionally, analyses were conducted to test the sensitivity of the cost-effectiveness ratios to outcome probability, average inpatient and emergency department costs, and proportion of poison exposures treated on site by the regional poison control center. A societal perspective was adopted. RESULTS: The regional poison control center was substantially more cost-effective than the treatment of poison exposures without the services of a regional poison control center for both outcomes (morbidity and mortality) in each of the poison exposures considered. The results of the sensitivity analyses demonstrated that the outcomes of the decision analyses do not change regardless of the type of poison exposure, outcome considered, clinical outcome probabilities, average inpatient and emergency department costs, and proportion of poison-exposure cases treated on site by a regional poison control center. CONCLUSIONS: The regional poison control center is consistently more cost-effective in the treatment of poison exposures with an average cost-effectiveness ratio (cost per successful outcome) approximately half of that achieved without the services of a regional poison control center. Finally, significant cost savings to society are realized for each additional successful outcome obtained with a regional poison control center.

Pharmacoeconomic research--facilitating collaboration among academic institutions, managed-care organizations, and the pharmaceutical industry: a conference report.

To provide a venue to allow for the exchange of information among parties interested in pharmacoeconomic research opportunities within managed-care organizations, an invitational conference was conducted by The University of Arizona's Center for Pharmaceutical Economics on January 20 and 21, 1994, in Tucson, Arizona. The purpose of the conference was to bring together representatives from managed-care organizations, academic institutions, and the pharmaceutical industry to discuss opportunities for collaboration, as well as consider the barriers to conducting pharmacoeconomic research in the managed-care setting. Challenges to collaboration include database development, the need for an integrated perspective, sensitivity to marketing matters, and a variety of technical and organizational barriers. To overcome these barriers, the interested groups must develop trust, recognize common ground, share risk, and communicate effectively. This article describes the emerging themes of the conference based on transcripts of formal presentations and participants' comments.

The role of colleges of pharmacy in meeting the pharmacoeconomic needs of the pharmaceutical industry: a conference report.

To provide a forum for the exchange of ideas regarding the role of colleges of pharmacy in meeting the pharmaceutical industry's pharmacoeconomic needs, an invitational conference was conducted by the University of Arizona's Center for Pharmaceutical Economics on January 14 and 15, 1993, in Tucson, Arizona. This article represents the program design, program types, and consensus development portions of that conference. A description of current needs in pharmacoeconomics was obtained through transcripts of industry and university presentations, panel discussions, and question-and-answer sessions. Conference participants generally agreed that pharmacoeconomics holds great potential for making significant contributions to health care but that it will not flourish without deliberate and cooperative efforts. Participants from both industry and academia voiced the need for the two parties to work together to increase the visibility and understanding of pharmacoeconomics and to meet the training and staffing challenges facing the discipline.

Patients' perceptions of increased pharmacy contact.

This prospective, randomized study was conducted to determine if increased patient contact between pharmacists and patients would result in greater patient awareness and satisfaction with their hospital stay and particularly with pharmacists and pharmacy services. Eligible patients were randomized to receive either the usual pharmacy care with minimum contact with the pharmacist, or expanded services based on increased contact with the pharmacist. A questionnaire was used to determine patient awareness and satisfaction. Statistically significant differences were found between the groups on awareness and satisfaction with pharmacy services scales as well as total scores. Total patient scores were highly reliable, with an alpha coefficient of 0.87. In addition, comments by patients in the group with increased contact were overwhelmingly positive, in contrast to those receiving usual care. Patients desire and appreciate greater contact with pharmacists.

Initial treatment choice in depression: impact on medical expenditures.

OBJECTIVE: The purpose of this study was to examine the economic outcomes associated with initial treatment choice following a diagnosis of depression. METHODS: Insurance claims data were used to classify patients into one of 4 treatment cohorts: no therapy, psychotherapy, drug therapy and combination therapy. Potential sample selection bias was accounted for by using a 2-stage econometric estimation procedure where initial treatment choice was estimated using a multinomial logistic regression model in the first stage, and total and mental healthcare costs were estimated in ordinary least squares regression models in the second stage. Log predicted costs from the second stage were compared to determine the relative costs associated with each cohort. RESULTS: Significant differences (p < 0.008) in total costs were found between the combination therapy (log predicted cost = 9.526) and psychotherapy cohorts (log predicted cost = 8.120) in the analysis that included all observations (n = 9110). In the analysis that included patients who initiated therapy with a non-mental health provider (n = 2673), the drug therapy cohort (log predicted cost = 8.238) was found to be significantly more costly as compared to the no therapy cohort (log predicted cost = 7.788). CONCLUSIONS: These results indicate that after controlling for both observed and unobserved factors, total healthcare costs may be higher in patients who initiate therapy with drug therapy and combination therapy as opposed to no therapy or psychotherapy. In addition, the finding that patients initially receiving psychotherapy alone tend to have higher mental healthcare costs but lower total healthcare costs than other patients may indicate that psychotherapy has an impact on comorbid illness and may subsequently reduce total healthcare costs.

Time preference for health gains versus health losses.

The purpose of this research was to determine whether people devalue further health gains differently from future health losses. 108 subjects in various states of health were randomised to groups that rated their preference for a hypothetical health gain or loss of variable duration and delay, in the condition of arthritis. Direction and duration of the hypothetical future health change had an interactive effect on time preference (p less than 0.001). For the health gain, devaluation due to delay was consistent across durations. For the health loss, devaluation depended on duration; the long-duration loss was devalued with delay while the fleeting loss was inflated. These findings cast doubt on the assumptions of positive time preference and constant rate discounting that underlie the classical model of discounting. They provide support for a theory of intertemporal choice which posits that vivid, fleeting, future events engender 'anticipation utility' which attenuates positive time preference. Our findings suggest that standard practices for discounting future health outcomes in economic evaluations of arthritis and possibly other conditions may need to be re-examined.

Construct validities of the Quality of Well-Being Scale and the MOS-HIV-34 Health Survey for HIV-infected patients.

This research assessed the construct validities of two health-related quality-of-life instruments: the Quality of Well-Being Scale (QWB) and the Medical Outcomes Study 34-item HIV Health Survey (MOS-HIV-34). A sample of 100 adult male, HIV-infected patients, across six HIV disease classifications, was used as subjects. Four convergent validity measures of health-related quality of life were used: CD4 cell counts, beta-2 microglobulin levels, disease classification, and age. All convergent validity measures were significant for the QWB. Forty percent of the convergent validity comparisons with the MOS-HIV-34 were statistically significant. Because the two measures provide different perspectives on health-related quality of life, both instruments appear to be useful in measuring health-related quality of life in this patient population.

Establishing the internal and external validity of experimental studies.

The information needed to determine the internal and external validity of an experimental study is discussed. Internal validity is the degree to which a study establishes the cause-and-effect relationship between the treatment and the observed outcome. Establishing the internal validity of a study is based on a logical process. For a research report, the logical framework is provided by the report's structure. The methods section describes what procedures were followed to minimize threats to internal validity, the results section reports the relevant data, and the discussion section assesses the influence of bias. Eight threats to internal validity have been defined: history, maturation, testing, instrumentation, regression, selection, experimental mortality, and an interaction of threats. A cognitive map may be used to guide investigators when addressing validity in a research report. The map is based on the premise that information in the report evolves from one section to the next to provide a complete logical description of each internal-validity problem. The map addresses experimental mortality, randomization, blinding, placebo effects, and adherence to the study protocol. Threats to internal validity may be a source of extraneous variance when the findings are not significant. External validity is addressed by delineating inclusion and exclusion criteria, describing subjects in terms of relevant variables, and assessing generalizability. By using a cognitive map, investigators reporting an experimental study can systematically address internal and external validity so that the effects of the treatment are accurately portrayed and generalization of the findings is appropriate.

Impact of clerkship students on pharmacy-site output.

The development of a theory-based method of estimating the impact of pharmacy clerkship students on clerkship sites is described. A job-analysis approach was used to estimate the impact of pharmacy clerkship activities on the clerkship sites. Two models--an employee model and a nonemployee model--of the student-preceptor relationship were used to evaluate clerkship student activities. Pairs of clerkship students and their preceptors were interviewed about student activities and supervision. Activities were assigned three-digit codes expressing (1) the level of preceptor supervision required, (2) the necessity of the activity to the functioning of the site, and (3) the complexity and amount of patient contact involved. The fit of each activity to the models was determined, and the impact of the clerkship students on a composite clerkship site was estimated. Twelve pairs of clerkship students and preceptors were interviewed. Degree of required supervision was the primary determinant in assigning an activity to a model. Student activities that fit the employee model were determined to have the greatest potential for having a positive or negative impact on the clerkship site. Performance of nonemployee-model activities could represent a net loss to the site because of the demand on preceptors' time. A method of categorizing and evaluating the value of specific student activities at pharmacy clerkship sites was useful in estimating student impact on the productivity of the site.

A retrospective analysis of the costs and consequences of a tobacco-cessation program for active duty service members.

Health system records of 126 active-duty (AD) service members who were participants in the Davis-Monthan AFB "Quitters are Winners" tobacco cessation program (QAWP) between June 1993 and May 1994 were reviewed retrospectively during the fall of 1994. Participants received an average of 2.84 (+/- 1.46) prescriptions for transdermal nicotine replacement therapy representing 6 weeks duration. Tobacco abstinence, determined by 6-month point prevalence abstinence (PPA), was 19.05 and 15.08% for 6-month continuous abstinence (CA). PPA and CA rates were significantly higher than expected (z = 3.94, p < 0.002; z = 2.38, p < 0.02). Average operational cost per successful outcome at 6 months after entry into the QAWP were $778.93 using PPA and $983.92 using CA. Additional analyses revealed corresponding increases between average cost per successful outcome and duration of TNRT. This research provides an initial analysis of the efficiency of the QAWP for AD participants and a model for subsequent evaluations within military medical treatment facilities.

Updating skills: pharmacoeconomics as continuing education.

With the increased numbers of pharmacoeconomic trials being conducted and reported, the practicing pharmacist will need to apply this information in formulary decision making. The review provides suggestions about readily available pharmacoeconomic continuing education opportunities for the practitioner. Examples of printed materials, home study programs, and meeting presentations are discussed. A combination of approaches is recommended.

Quality of life. 2. Economic analysis of drug therapies.

In 1990, health care expenditures in the United States reached $666.2 billion, 12.2% of the gross domestic product (GDP). It is projected for the year 2000, the USA will spend $1.6 trillion for health care which will be comparable to 16.4% of that year's GDP. As a result of the rapid increase in costs of health care and limited resources available, patients, third-party payers and the government have initiated and implemented more rigid cost control measures. Economic analyses can help ensure the efficient use of health care dollars in areas such as drug therapy. The four methodologies available are cost-benefit analysis, cost-effectiveness analysis, cost-minimization analysis and cost-utility analysis. This article reviews methods and provides examples from the medical literature. These tools can assist care providers in determining which treatments are most cost-effective.

Evaluating the results of mail survey research.

OBJECTIVE: To present overall guidance enabling the reader to critically evaluate survey research conducted via mail questionnaire. Also considered are the sources of error that may operate during the conduct of survey research and the threats they pose to both the internal rigor of the study and the generalizability of the results. STUDY SELECTION: Not applicable. DATA EXTRACTION: Not applicable. DATA SYNTHESIS: Not applicable. CONCLUSION: Survey research has been used so commonly and for such a wide range of purposes in a large number of fields, that some people may mistakenly conclude that surveys are easy to conduct. Survey research involves much more than generating a set of questions to ask a group of subjects. To draw valid conclusions about the topic of a survey, the pharmacist must be prepared to evaluate the results in light of how well the investigators approached four sources of error--coverage, sampling, measurement, and nonresponse. The evaluation of survey administration procedures primarily concerns determining whether or not a pilot study was conducted, whether proper statistical analyses were conducted, and whether multiple mailing procedures were used. Failure to account for these sources of error, or inappropriate survey administration, could seriously affect both the generalizability and validity of the results.

HIV infection and AIDS: attitudes and knowledge of Arizona pharmacists.

OBJECTIVE: To assess Arizona pharmacists' attitudes and knowledge regarding HIV infection and AIDS. METHODS: Mailing of a 7-page survey, which included demographic and attitudinal items, as well as preparedness, comfort, and knowledge scales. SETTING: Randomly selected pharmacists registered and residing in Arizona. PARTICIPANTS: Of the 479 pharmacists surveyed, 41 were removed from the sample because they had moved with no forwarding address, were retired or not practicing, or had died. The response rate was 46% for the remaining 438 pharmacists. A final sample size of 199 was obtained. RESULTS: The respondents had a high level of preparedness and comfort in addition to positive attitudes. Overall, their knowledge level was low. Inpatient pharmacists had a higher level of therapeutic knowledge (p < 0.0001) and were more willing to work with a person infected with HIV than were outpatient pharmacists (p = 0.05). Pharmacists who had attended at least 1 HIV/AIDS-related continuing education (CE) program had higher levels of preparedness (p < 0.0001), comfort (p = 0.01), and knowledge (p < 0.0001) than those who had not. The majority of respondents believed that an HIV/AIDS CE program should be mandatory. CONCLUSIONS: Although Arizona pharmacists feel prepared, are comfortable, and have positive attitudes regarding patients with HIV/AIDS, their level of knowledge is low. The results of this study may be used by CE providers to design programs to meet the educational needs of pharmacists.

Economic analyses in hypertension: applications for healthcare providers.

Hypertension affects millions of Americans. With healthcare dollars becoming more closely scrutinized, economic studies are playing an important role in helping decision makers choose who should receive treatment and which treatments and methods of administration are most cost-effective. This article provides an overview of the different methods used in economic evaluation and demonstrates the utility of each method using studies from the hypertension literature.

Drug-use evaluation programs in short-term-care general hospitals.

The results of a survey to assess drug-use evaluation (DUE) programs in short-term-care general U.S. hospitals are reported. During February 1992, questionnaires were mailed to pharmacy directors at 491 randomly selected short-term-care general hospitals with 100 or more beds. The questionnaire was designed to collect information on the characteristics of surveyed hospitals and their pharmacies, DUE program characteristics, and the perceptions of pharmacists about the DUE programs. The net response rate was 66.6% (327 usable replies). Pharmacists involvement in DUE program activities was found to be very high, with two thirds of respondents indicating they participated in all five ASHP-recommended activities. Pharmacists rated the effectiveness of current DUE programs as moderate, while the importance of pharmacist participation was perceived to be very high. Pharmacists were members of 97.9% of the respondents' DUE committees, but only 65.5% of the pharmacist members held voting privileges. Pharmacists reported devoting an average of 11.27 hours weekly to DUE-related tasks. Reasons used to select drugs for DUEs, interventions employed, uses of DUE results, and methods of evaluating the effectiveness of DUE programs all varied widely. In short-term-care general hospitals with 100 or more beds, pharmacists assigned to DUE activities were highly involved in DUE committees and programs. The effectiveness of these activities needs to be assessed in more detail.

Community pharmacy residency programs, 1997-1998.

OBJECTIVE: To obtain a descriptive "snapshot" of community pharmacy residency programs active in 1997-1998. DESIGN: Survey (telephone interview) of community pharmacy residency program directors. METHODS: An advance letter to residency directors stated the purpose of the study and requested written information on their residency program. Using a scripted questionnaire, telephone interviews were conducted with each residency director. RESULTS: Descriptive statistics were used to portray the data. There were 13 active community pharmacy residency programs with 20 filled residency sites nationwide at the time of the study. Results revealed that 9 (69%) programs were funded by multiple sources, 3 programs were funded solely by the affiliated college, and 1 program was funded solely by the affiliated pharmacy. Of the 10 residency programs that had been in existence for longer than 1 year, 7 (70%) had the same funding source as they did the first year. Respondents provided descriptions of the residency programs, along with insight into the challenges of creating such programs. At the time of publication (November 1999), there were 50 active community residency sites within the 21 active community pharmacy residency programs. Several other programs are planned for implementation in July 2000. CONCLUSION: In general, community pharmacy residency programs continue to grow in number, and funding has been sustained due to the programs' successful outcomes. The results of this study provide a framework for the improvement of existing community pharmacy residency programs and the development of additional ones.

The production model as a basis for conducting economic evaluations of regional poison control centers.

To identify the significant inputs, activities, and outputs of a regional poison control center, a production model is described and its potential application to the conduct of economic evaluations delineated. The model can help the researcher identify the significant inputs (costs) incurred through the provision of poison control center services. These inputs directly influence the activities that the poison center is capable of undertaking. Activities undertaken by a poison center are intermediate steps between the inputs and outputs, and serve to convert the various inputs into associated outputs. They form the basis for determining the outputs produced by the poison center services. The outputs derived from poison center services provide the conceptual framework for assessing the effectiveness of a poison center in an economic analysis. Also described are potential applications of the production model in conducting poison center cost-effectiveness and cost-benefit analyses.

Reliability of an Arabic version of the RAND-36 Health Survey and its equivalence to the US-English version.

OBJECTIVES: The objectives of this research were to: (1) evaluate the reliability and equivalence of the Arabic and English versions of the RAND-36 Health Survey (RAND-36) in a sample of Saudi Arabian citizens; and (2) assess the health status of a sample of Saudi Arabian citizens using both the Arabic and English versions. METHODS: Both the Arabic and English versions of the survey were administered to a convenience sample of bilingual (English and Arabic) Saudi citizens (n = 415) at Saudi ARAMCO Company, Dhahran, Saudi Arabia. Internal consistency, equivalent-forms, and test-retest reliability were estimated for the eight multi-item scales in the Arabic and English versions. Mean scale scores were calculated for each version and compared with the general US populations. RESULTS: The median Cronbach's alphas for the Arabic RAND-36 in multiple subgroups exceeded 0.70 for every scale except one. Two of the English RAND-36 scales had median Cronbach's alphas that exceeded 0.70; the remainder exceeded 0.50. Two-week test-retest correlations were all statistically significant for both versions. Product-moment correlations to test the equivalence of the corresponding Arabic and English versions of the RAND-36 ranged from 0.73 to 0.92. Saudi citizens reported significantly higher vitality scores, but significantly lower physical functioning, social functioning, and general health perception scores than the general US population. CONCLUSIONS: The results provide support for the reliability and equivalence of the Arabic and English versions of the RAND-36. Additional studies need to be conducted in a representative sample of the general Saudi population to further assess the psychometric properties of the Arabic version.

Equivalence of Chinese and US-English versions of the SF-36 health survey.

This study evaluated the equivalence of Chinese and US-English versions of the SF-36 Health Survey in a convenience sample of 309 Chinese nationals bilingual in Chinese and English living in a US city. Snowball sampling was used to generate sufficient sample size. Internal consistency, test-retest, and equivalent-forms reliability were estimated. Patients were randomized to one of four groups: (1) English version completed first, followed by Chinese version (same occasion); (2) Chinese version completed first, followed by English version (same occasion); (3) English version completed once and then again 1-week later; (4) Chinese version completed once and then again 1-week later. Internal consistency reliability estimates for the Chinese and US-English versions of the SF-36 scales ranged from 0.60 to 0.88; test-retest reliability estimates (1 week time interval) ranged from 0.67 to 0.90. Reliability estimates for corresponding Chinese and US-English SF-36 scales tended to be similar and not significantly different. Equivalent-forms reliability estimates (product-moment correlations) ranged from 0.81 to 0.98. Mean SF-36 scale scores were comparable for both versions of the instrument. This study provides support for the equivalence of the Chinese and US-English versions of the SF-36.