Medication use characteristics in the elderly: the Iowa 65+ Rural Health Study.

Medication use was studied in a rural, elderly population. Household interviews were conducted of 3,467 individuals aged 65 years or older. A total of 9,955 prescription or nonprescription drugs were reported by the respondents. The overall mean number of drugs per respondent was 2.87, while 12% of all respondents were not taking any drugs. Mean prescription and overall drug use increased significantly with increasing age (P less than .001), while mean nonprescription drug use was relatively constant across age groups. Significantly more women were prescription and nonprescription drug users. Directions for scheduled daily dosing accounted for 75% of all directions. The majority of prescription and nonprescription drugs had been taken on the previous day. General practitioners accounted for more prescription drugs (39.7%) than any other medical specialty. The most frequently stated purpose was cardiovascular for prescription drugs and musculoskeletal for nonprescription drugs. The three most frequent prescription drug therapeutic categories were cardiovascular (54.7%), central nervous system (CNS) agents (11.4%), and analgesics (9.4%). For nonprescription drugs, the three most frequent therapeutic categories were analgesics (39.6%), vitamins and minerals (32.9%), and laxatives (14.1%). Implications of these findings are discussed.

How to develop and implement a program to continuously demonstrate the value of clinical pharmacy services.

This paper summarizes key elements that support the success of clinical pharmacy services to continuously improve the quality of drug therapy. Five drivers identify a successful model for continuously demonstrating the value of clinical pharmacy services: knowing the organizational culture; providing leadership; recruiting pharmacy sponsors; showing tenacity; and acting with management courage. Difficulties encountered when communicating the value of clinical pharmacy services within a health care organization usually arise because of failure to include one of these drivers.

Use and costs under the Iowa capitation drug program.

This article evaluates changes in the use of drug services and the corresponding costs when the conventional fee-for-service system for reimbursement of pharmacists under medicaid is replaced by a capitation system. The fee-for-service system usually covers ingredient costs plus a fixed professional dispensing fee. The capitation system provided a cash payment (which varied by aid category and season of the year) per Medicaid eligible the first of each month. We examined drug use and costs in two experimental rural counties during a 1-year preperiod in which the fee-for-service form of reimbursement was employed, as well as a 2-year postperiod in which the capitation system was used. We compared the results with use and cost patients in two other rural counties which remained on the fee-for-service system during the same 3-year period. Drug use was similar among control and experimental counties with the exception of nursing home patients; use in this category decreased under capitation and increased under fee-for-service. Using three measures of drug cost: 1) average cost of a day's drug therapy; 2) average drug costs per recipient; and 3) average Medicaid expenditures for drug services per recipient, we observed significant savings under the capitation reimbursement system as compared to the fee-for-service system. We attributed savings under capitation to shifts in prescribing and dispensing behavior, as well as changes in use by nursing home patients. Based upon these findings, the total savings resulting from implementing capitation would be approximately 16 percent compared to fee-for-service reimbursement.

Susceptibility patterns of Staphylococcus in a family practice population.

Nasal swabs were obtained from 408 patients seen in a family practice office in an attempt to identify Staphylococcus aureus carriers. Isolated strains were tested for sensitivity to 11 antibiotics. Study participants were interviewed to obtain the following data: age, history of recent hospitalization and/or recent antibiotic use, number of household members, and occupation, if employed in a health-care facility. S aureus was isolated from 109 nasal swabs. This represents a 26.7 percent carrier rate. Only 25.7 percent of the isolates were sensitive to penicillin G and ampicillin. No statistically significant association was found between the patient variables and either the carrier rate or the sensitivity of the S aureus isolates to penicillin. The sensitivity testing demonstrated that 94.5 percent of the isolates were sensitive to tetracycline and erythromycin. Ninety-nine to 100 percent of the isolates were sensitive to all other antibiotics tested. The authors conclude that penicillin G should not be used in the treatment of S aureus infections. Erythromycin, due to demonstrated sensitivity and reasonable cost, is recommended for mild to moderate infections.

Multicenter study of family physician prescribing.

The objective of this study was to examine differences in prescribing characteristics among four Iowa family practice offices, each associated with family practice residency programs. This prospective study collected data over a four-month period, utilizing duplicate, carbon-copy prescriptions. The prescriptions were tabulated according to individual drug and therapeutic categories. Differences in prescribing frequency among offices were analyzed using chi-square 2 X 2 contingency tables. The number of prescriptions written at each office (designated A through D) were as follows: A, 1,034; B, 1,449; C, 2,965; and D, 2,335. The most frequently prescribed drug category was systemic antibiotics, followed by cough, cold, or allergy products, analgesic and anti-inflammatory drugs or muscle relaxants, diuretics, and topical anti-infectives. There were statistically significant differences in the frequencies of these categories among offices. The most frequently prescribed drug was amoxicillin at offices A, B, and C, and erythromycin at office D. There were statistically significant differences in the frequencies of the top ten drugs at each office. From these data the family practice faculty and clinical pharmacists can identify therapeutic areas that may require additional educational emphasis for the resident.

Patient care telephone calls received in family practice offices.

The majority of patients care calls referred to practitioners at each of two family practice office study sites were related to medications. However, there were significant differences in the proportion of patient care calls managed by staff physicians, family practice residents, and clinical pharmacists which involved discussion of medication. There were also significant differences in the callers and types of medication related calls managed by each practitioner group. Calls initiated by patients and those classified as refill requests accounted for the largest proportion of calls managed by staff physicians, residents, and clinical pharmacists. The majority of calls received by each practitioner group were managed without consultation. A follow-up office visit was recommended in approximately one half of all medication related calls. The findings of this study may be useful in determining the personnel required to manage medication related telephone calls and in identifying potential areas for education and training of personnel in family practice.

The use of subtherapeutic antibiotics in animal feed and its implications on human health.

Antibiotics were approved for use as animal feed additives in 1950 after it was discovered that their use increased growth rate, improved feed utilization, and reduced mortality and morbidity from clinical and subclinical infections in animals. Subtherapeutic use of antibiotics in animal feed grew extensively and concern has arisen that this "indiscriminate" use of antibiotics could lead to increased numbers of antimicrobial-resistant bacteria and ultimately compromise treatment of human bacterial infections. Three recently published studies seem to indicate that animal-to-man transmission of antimicrobial-resistant bacteria is possible. Increased debate on the continuing allowance of antibiotic feed additives has ensued. The National Resources Defense Council has recently petitioned the FDA to disallow penicillin and tetracycline use in animal feed, and legislation has been introduced in the U.S. House of Representatives that would limit the subtherapeutic use of antibiotics in animal feed. Experts have predicted that meat prices would increase and meat quality would decrease if antibiotics are disallowed as a feed additive. It is the opinion of the authors that there is no conclusive evidence at this time to support the premise that subtherapeutic use of antibiotics in animal feed poses a greater threat to human health than if antibiotic feed additives were banned.

Dilemmas in primary care: antibiotic treatment of acute otitis media.

Antibiotic treatment of acute otitis media (AOM) accounts for a significant number of all antibiotic prescriptions each year. In the primary care setting, initial antibiotic selection is rarely based on direct evidence, such as cultures of middle ear fluid. Initial antibiotic therapy by the primary care practitioner involves the evaluation and application of information related to prevalence of infecting organisms; in vitro antibiotic spectrum and penetration into middle ear fluid; initial cure rate, relapse and recurrence rates; and antibiotic cost, safety, and convenience. The influence of these factors on the initial antibiotic choice for AOM is reviewed. Several therapeutic dilemmas confronting the prescriber are discussed and a rational approach to initial antibiotic therapy is presented.

Ambulatory care pharmacy services: the incomplete agenda.

OBJECTIVE: To review studies that document the impact of clinical pharmacy services in ambulatory care settings and to propose standards of practice and resource allocation needs in ambulatory care. DATA SOURCES: English-language literature from 1970 through 1991 was reviewed and the representative literature is described. STUDY SELECTION: Studies were selected that examined the impact of clinical pharmacy services on patient outcomes and costs. Studies that evaluated pharmacist consultations by blind peer-review panels were also evaluated. DATA EXTRACTION: Trials were assessed based on their methodologies and ability to assess the value of clinical pharmacy services on patient outcomes. DATA SYNTHESIS: Numerous studies from the past 20 years are described illustrating the impact that ambulatory care pharmacy practitioners have made on patient care. These studies demonstrate that clinical pharmacists in ambulatory care not only serve as consultants on pharmacotherapy issues, but also can improve the quality of care for individual patients. CONCLUSIONS: Based on the studies cited and the needs of ambulatory patients, this article highlights the authors' views on what the standards of practice should be for ambulatory care practitioners and where resources should be allocated as ambulatory programs are expanded.

Ambulatory care pharmacy services: has the agenda changed?

OBJECTIVE: To provide an extensive review of ambulatory care clinical pharmacy services and evaluate the services and research data in the field. DATA SOURCES: MEDLINE was searched from January 1992 through July 1999. Search terms included pharmacy, clinical pharmacy, and pharmaceutical care, cross-referenced with ambulatory care, primary care, family medicine, and managed care. STUDY SELECTION: Relevant peer-reviewed studies and reports since our previous article in 1992 were selected and described. Literature prior to 1992 was briefly reviewed. DATA SYNTHESIS: The relevant literature was reviewed and some examples from the authors' institutions are provided. Much research has continued to be published documenting the value of clinical pharmacy services in ambulatory care, including in community pharmacy, anticoagulation services, family medicine, primary care clinics, Veterans Affairs Medical Centers, and managed care. However, these innovative services are underrepresented in the community at large. The vast majority of the public does not have access to these types of services. CONCLUSIONS: There will be continued and dramatic expansion of ambulatory care pharmacy services in the new decade beginning in the year 2000. It will be critical that standards of practice be very high. We believe there is a critical need for visible demonstration projects and large multicenter research projects that demonstrate the value of these services.

Inadequately written prescriptions: prescriber rationales for "take as needed" and "take as directed.".

An audit of a large sample of prescriptions written by 39 physicians revealed considerable variation in the rate at which they specified adequate dosage instructions. When asked for their rationales for saying "Take as needed" or "Take as directed" on prescriptions, the physicians cited several circumstances where these instructions may be indicated. "Take as directed;; is defended 1) when the patient has a history of compliance with the regimen being prescribed; 2) when the prescription is accompanied by verbal or auxiliary written instructions; 3) when oral contraceptives are ordered; and 4) when the prescribers may need to make frequent changes in a regimen and wish to communicate these changes orally. "Take as needed" is defended when the drug is to be taken only when the patient determines that sufficient symptoms have appeared. Prescribers are cautioned to consider whether the assumed advantages of nonspecific dosage instructions are outweighed by the possible risks of patient confusion.

The effect of clinical pharmacy services on family practice residents' attitudes: a nationwide study.

A nationwide study investigated the attitudes of family practice residents toward: interdisciplinary health care teams in family practice; the clinical pharmacist as a member of the health care team; and the utility of clinical pharmacist involvement in private family practice offices. A random sample of 174 family practice residency programs was selected for study. First-year residents comprised the sample population. Based on the response of the directors, programs were assigned to experimental (programs offering clinical pharmacy services) or control (no clinical pharmacy services) groups. Completed attitudinal instruments were received from 158 resident respondents in the experimental group and 153 resident respondents from the control group. The reliability coefficient of the returned questionnaires was 0.901 by the split-halves method. Residents in the experimental group had significantly more favorable attitudes than those residents in the control group on several scales. These scales included the clinical pharmacist's participation on the health care team, utility of a clinical pharmacist in a private practice setting, desirability of hiring a clinical pharmacist, and the desirability of practicing with a multidisciplinary health care team. These results support the hypothesis that exposure to clinical pharmacy services can significantly affect physician resident's attitudes toward clinical pharmacy.

Antiulcer prescribing program in a state correctional system.

OBJECTIVE: To describe a formulary antiulcer agent prescribing program developed as the result of a drug use evaluation (DUE). Program implementation, methods, cost impact, and results of a follow-up DUE are provided. BACKGROUND: The institution is a 51,000-bed correctional system consisting of 40 separate units each containing an ambulatory care clinic. Medication orders are transmitted via mainframe computer system to one of four pharmacies, which collectively dispense an average of 4000 medication orders (30 days' supply) per day. METHODS: Results from the antiulcer agent (cimetidine, ranitidine, sucralfate) DUE revealed that the agents studied were prescribed in dosages and durations exceeding criteria developed by the Pharmacy and Therapeutics Committee. A program designed to reduce dosages to maintenance therapy after eight weeks at treatment dosage was developed by the Pharmacy and Therapeutics Committee with staff physician input. Antiulcer agent use and expenditures were followed and a follow-up DUE was completed seven months after program implementation. Antacid use and frequency of upper gastrointestinal studies that were ordered were followed. RESULTS: The follow-up DUE showed the mean daily dosage for prescribed histamine2-receptor antagonists decreased (cimetidine from 694 to 454 mg, ranitidine from 280 to 183 mg) and the mean duration of therapy decreased from 14 to 10 months. The percentage of patients with potentially significant drug interactions decreased from 14.2 to 6.5 percent. The mean number of antiulcer agents dosage units dispensed per month decreased by 24,461 units, resulting in a projected annual savings of $327,273. There were no identifiable clinically important changes in the use of antacid products or prescribing of upper gastrointestinal studies. CONCLUSIONS: A cost-savings program sponsored by the pharmacy and therapeutics committee decreased costs, corrected prescribing to more closely meet preset criteria, and produced no discernable unfavorable effect on patient care.

Clinical pharmacy services in family practice: cost-benefit analysis. II. Referrals, appointment compliance, and costs.

The benefits, decreased referral rate and increased kept-appointment rate, and the costs that a family practice clinic could expect to incur by including a clinical pharmacist in the clinic are discussed. By using a clinical pharmacist as a consulting partner, the physician would have a decreased need to refer patients to specialists not affiliated with the medical practice. The benefit to the practice is the revenue from office and hospital visits that would not have been received had these patients been referred elsewhere. Involvement of a clinical pharmacist in providing drug therapy management for patients with selected chronic diseases results in an increase in office appointment compliance rates. The benefit to the practice is the revenue generated by the increased number of office visits per year. Costs that would be incurred by the practice include: physician time spent due to the increased number of office visits generated by the decreased referral rate and increased appointment compliance; increased operating expenses, including the clinical pharmacist's salary and fringe benefits; and the developmental expense of establishing a reference library for the clinical pharmacist.

Clinical pharmacy services in family practice: cost-benefit analysis. I. Physician time and quality of care.

The objectives of this study was to identify benefits and costs that a family practice clinic could expect to incur by including a clinical pharmacist in that clinic, to derive equations to estimate the magnitude of each benefit and cost, to discuss the rationale for each equation, and to demonstrate the application of these equations through the use of sample calculations. The benefits, freed physician time and improved quality of care, are discussed. The physician's time is freed since the clinical pharmacist can provide many services that were provided previously by a physician. Quantification is based on a determination of the amount of time spent by physicians in providing specific services and the proportion of those services that could be assumed by a clinical pharmacist. Literature sources document an improvement in quality of care due to clinical pharmacy services. The principle used to quantify this improvement in the quality of care involves determining a monetary value for this care before the addition of a clinical pharmacist. This baseline quality of care value is then multiplied by the projected fractional increase in the overall quality of care that would result from the inclusion of a clinical pharmacist.

An assessment of prescribing using drug utilization review criteria.

Drug utilization review screening criteria were applied to a sample of 30 000 prescriptions written by Iowa physicians. Characteristics of the physicians who had high percentages of prescriptions violating the explicit criteria were examined. It was found that the proportion of prescriptions failing the screening criteria did not differ significantly among physicians of differing board certification groups, medical school of graduation, year of graduation from medical school, age, or size of town where the physicians practiced. Regardless of the physicians' demographic characteristics, approximately 50 percent of their prescriptions violated the prescribing criteria. The three categories of screening criteria included irrational mixture, quantity prescribed, and daily dosage. An analysis of the relationship between physician ratings obtained for each of the categories revealed that no relationship existed between a physician's quantity prescribed rating and daily dosage rating, or between a physician's irrational mixture rating and daily dosage rating. A negative relationship was found between a physician's quantity prescribed rating and irrational mixture rating. This tends to indicate that the three categories measure different prescribing patterns and each warrants respective monitoring by pharmacists.

Model for cost-benefit analysis of clinical pharmacy in family practice.

A cost-benefit analysis (CBA) model that can be used to estimate the economic consequences expected from the inclusion of clinical pharmacy services in a family practice clinic was developed; use of the model was demonstrated by applying it to a hypothetical solo-physician practice. The effects that clinical pharmacy services would have on the medical practice were evaluated and classified as either costs or benefits. Equations were derived to quantify all direct effects. Semi-structured, open-ended interviews of 15 family practice physicians and five family practice clinical pharmacists were conducted to generate data describing a hypothetical solo-physician practice. Responses from these interviews were averaged to provide the numerical values called for by the equations in the CBA model. The difference between total costs and total benefits was the net benefit that could be expected by the hypothetical solo-physician practice for the first year after including a clinical pharmacist in that practice. The net benefit determined by these calculations was $2744 assuming a 5% increase in overall quality of care, or $25,658 assuming a 20% increase in overall quality of care. The net-benefit figure obtained by applying the CBA model to the hypothetical case should not be generalized to other practices. Rather, by applying the CBA model, practitioners and administrators can calculate the expected net benefit specific for their particular medical practice.