Prescription of acid-suppressing drugs in relation to endoscopic diagnosis: a record-linkage study.
(9/2434)
BACKGROUND: Although widely used, few data are available on the appropriateness of prescribing of acid-suppressing drugs (ASDs), despite guidelines on the investigation and treatment of dyspeptic patients. METHODS: We created a database of 62 000 endoscopy examinations and record-linked these to a prescribing database. Endoscopic diagnoses were classified into peptic, nonpeptic and others. The H2-antagonists, omeprazole and misoprostol, were studied. RESULTS: 35 000 patients had one or more endoscopies during 1978-93; two-thirds were over 45 years of age at first endoscopy. A quarter of all patients who had been endoscoped had consistently normal examinations. Peptic oesophageal pathology was the commonest positive finding. A quarter of those prescribed ASDs between 1989 and 1993 had been endoscoped between 1978 and 1993. In those with a peptic diagnosis prescribed any ASD, the pathologies found were: oesophageal (42.9%), duodenal (36.3%) and gastro-pyloric (21.3%). Patients prescribed omeprazole were more likely to have undergone endoscopy than those prescribed other ASDs, and they were also more likely to have peptic oesophageal pathology. Long-term prescribing (>56 days per year) occurred in two-thirds of patients prescribed ASDs and 40% had at least one endoscopy. In those prescribed short-term ASDs, 20% had undergone at least one endoscopy. Peptic and nonpeptic endoscopic pathology was associated with increased ASD prescribing, but a normal endoscopy did not reduce prescribing. CONCLUSION: ASD prescribing appeared to be mainly symptom-driven. Positive endoscopic findings increased the prescribing of ASDs, but normal findings did not reduce it. (+info)
Ward pharmacy: a foundation for prescribing audit?
(10/2434)
OBJECTIVES: To determine the extent and nature of prescription monitoring incidents by hospital pharmacists and to derive a performance indicator to allow prescription monitoring to be compared among hospitals in North West Thames region. DESIGN: Survey of all self recorded prescription monitoring incidents for one week in June 1990. SETTING: All (31) acute hospitals in the region with pharmacy departments on site, covering 10,337 beds. SUBJECTS: 210 pharmacists. MAIN MEASURES: Number of prescription monitoring incidents recorded, their nature, and outcome; a performance indicator of prescription monitoring (incidents/100 beds/week) and its variation according to specialty and site. RESULTS: 3273 prescription monitoring incidents were recorded (median 89 per hospital, range 3-301), the most common being related to the dose and frequency of administration of the drug (933 incidents, 29%). These incidents led to alterations of prescriptions on 1611 occasions; the pharmacist's advice was rejected on 81. The greatest number of prescription monitoring incidents/100 beds/week by specialty was recorded for intensive therapy units (median 75); the medians for medicine and surgery were 32 and 21 respectively. This performance indicator varied 20-fold when analysed by site, values ranging from 3.6 to 82.1 (median 29.8). CONCLUSIONS: Hospital pharmacists play a large part in monitoring and improving prescribing, and most of their interventions are related to the basics of prescribing. They therefore have a role in medical audit, working with clinicians to identify prescribing problems, and to set standards and monitor practice. A performance indicator of prescription monitoring incidents/100 beds/week allows comparison of pharmacists' activities among sites and may be a valuable tool in auditing them. (+info)
Pediatric discharge against medical advice in Bouake Cote d'Ivoire, 1980-1992.
(11/2434)
Discharge information was obtained from pediatric ward logbooks of the Centre Hospitalier Regional de Bouake from 1982 to 1992. While number of children admitted per month and discharge diagnosis remained relatively stable throughout the period, the proportion of children who left the hospital against medical advice increased by nearly 5 times during the 11-year period to over 12% of all pediatric admissions. The proportion of discharges against medical advice decreased to 10% of all pediatric admissions after institution of a programme to provide essential drugs at cost to patients (previously only available from private pharmacies). Most children who were taken from the hospital left within the first two days of hospitalization. The admission diagnoses of these children suggest that most had serious, life-threatening illness and that they left the hospital prior to having received adequate treatment. The increase in pediatric ward discharge against medical advice occurred simultaneously with serious budgetary shortfalls in the hospital resulting in inadequacy of medicines and basic equipment. Hospital staff suspected that most of the discharges against medical advice were caused by families being unable to afford the purchase of medicines and supplies necessary for inpatient treatment. It is suggested that widespread policies of decreasing funding for basic curative services in public hospitals may be associated with a substantial increase in preventable child mortality. (+info)
Potential savings from generic prescribing and generic substitution in South Africa.
(12/2434)
Generic prescribing and generic substitution are mechanisms for reducing the cost of drugs. The purpose of this study was to assess the extent to which generic prescribing by private medical practitioners and generic substitution by private pharmacists is practised in South Africa and to estimate the potential savings from these two practices. Prescriptions from 10 pharmacists were collected on four randomly selected days. Computer printouts of all the prescriptions dispensed on these four days together with the original doctor's prescription were priced using a commercially available pharmacy dispensing computer package. A total of 1570 prescriptions with a total number of 4086 items were reviewed. Of the total prescriptions, 45.7% had at least one item for which there was a generic equivalent. Of the 961 drugs which had generic equivalents, 202 (21 %) were prescribed using the generic name of the drug. Only 0.3% of prescribers prohibited generic substitution. The cost of the prescription as dispensed was 1.4% (mean cost: R116.19 vs R117.84) below that of the original doctor's prescriptions, indicating the marginal benefit from the current low substitution rate of 13.9% by pharmacists. About 6.8% of the cost of the original doctor's prescriptions (mean cost: R117.84) could have been saved if total generic substitution (mean cost: R109.65) was practised. The cost of the prescriptions with only brand name items (mean cost: R120.49) would have been 9.9% higher than if generic drugs were used. Current restrictive prescribing and dispensing practices result in marginal cost savings from generic prescribing and generic substitution. Both these practices have a potential to reduce drug costs, if actively encouraged and practised to maximum capacity. It is noteworthy, however, that the potential savings from generic prescribing and substitution are at most 9.9% in the absence of any changes in types of drugs prescribed. (+info)
Use of ineffective or unsafe medications among members of a Medicare HMO compared to individuals in a Medicare fee-for-service program.
(13/2434)
Adverse drug reactions and inappropriate prescribing practices are an important cause of hospitalization, morbidity, and mortality in the elderly. This study compares prescribing practices within a Medicare risk contract health maintenance organization (HMO) in 1993 and 1994 with prescribing practices for two nationally representative samples of elderly individuals predominantly receiving medical care within the Medicare fee-for-service sector. Information on prescriptions in the fee-for-service sector came from the 1987 National Medical Expenditures Survey (NMES) and the 1992 Medicare Current Beneficiary Survey (MCBS). A total of 20 drugs were studied; these drugs were deemed inappropriate for the elderly because their risk of causing adverse events exceeded their health benefits, according to a consensus panel of experts in geriatrics and pharmacology. One or more of the 20 potentially inappropriate drugs was prescribed to 11.53% of the Medicare HMO members in 1994. These medications were prescribed significantly less often to HMO members in 1994 than to individuals in the fee-for-service sector, based on information from both the 1987 NMES and the 1992 MCBS. Utilization of unsafe or ineffective medications actually decreased with increasing age in the HMO sample, with lowest rates in individuals over the age of 85. However, no relationship between age and medication use was seen in the NMES study, except for individuals over the age of 90 years. The study data support the conclusion that ineffective or unsafe medications were prescribed less often in the Medicare HMO than in national comparison groups. In fact, for the very old, who are most at risk, the use of these medications was much lower in the Medicare HMO than in the Medicare fee-for-service sector. Nevertheless, in 1994, approximately one of every nine members of this Medicare HMO received at least one such medication. Continued efforts and innovative strategies to further reduce the use of unsafe and ineffective drugs among elderly Medicare HMO members are needed. (+info)
Aspirin treatment after myocardial infarction: are health maintenance organization members, women, and the elderly undertreated?
(14/2434)
In April 1996, we surveyed 539 patients who had suffered a myocardial infarction in 1995 to determine whether the prescription and use of aspirin after myocardial infarction differs by patient age, sex, and type of health insurance. Patients who were insured through one of four health maintenance organizations in major metropolitan areas or by an indemnity plan in 40 states completed the survey. Among the 502 patients with no contraindications to use, 93.8% were prescribed aspirin. Among patients with a prescription and no subsequent contraindications to use, 96.4% were taking aspirin when surveyed. Among aspirin users, 96.5% reported taking aspirin daily. Controlling for other characteristics, 75-year-old patients were 5 percentage points less likely to receive a prescription for aspirin than were 50-year-old patients (P = 0.05). Although not significant at conventional levels, point estimates revealed a prescription rate for women that was 6 percentage points higher than that for men (P = 0.054) and a rate for health maintenance organization members that was 4 percentage points lower than that for patients with indemnity insurance (P = 0.10). Aspirin use was lower among older patients (P = 0.02) but did not differ by gender or type of insurance plan. Health maintenance organization members were just as likely to receive a prescription from a specialist as were those with indemnity insurance (P = 0.92). Based on these results, the rate of aspirin treatment after myocardial infarction may be much higher than previous studies indicate. Concerns that managed care patients and women may be undertreated are not supported by our findings. Although older patients are at risk for undertreatment, this risk is low. Once aspirin is prescribed, selfreported patient compliance with a daily regimen of aspirin is high. (+info)
Performance of village pharmacies and patient compliance after implementation of essential drug programme in rural Burkina Faso.
(15/2434)
After implementation of a nation-wide essential drug programme in Burkina Faso a prospective study was undertaken consisting of non-participant observation in the health centre and in the village pharmacy, and of household interviews with the patients. The study covered all general consultations in nine health centres in three districts over a two-week period as well as all client-vendor contacts in the corresponding village pharmacies; comprising 313 patients in consultations and 498 clients in eight village pharmacies with 12 vendors involved in dispensing 908 drugs. Additionally patients were interviewed in their households. Performance and utilization of the village pharmacy: 82.0% of the drugs prescribed in the health centres were actually dispensed at the village pharmacy, 5.9% of the drugs were not available at the village pharmacy. Wrong drugs were dispensed in 2.1% of cases. 41.3% of the drugs dispensed in the village pharmacy were bought without a prescription. Differences are seen between the district and are put in relation to different onset of the essential drug programme. Patient compliance: Patients could recall the correct dosage for 68.3% of the drugs. Drug taking compliance was 63.1%, derived from the pills remaining in the households. 11.5% of the drugs had obviously been taken incorrectly to such an extent that the occurrence of undesired drug effects was likely. The study demonstrates the success of the essential drug programme not only in performance but also in acceptability and utilization by the population. (+info)
Cost recovery in Ghana: are there any changes in health care seeking behaviour?
(16/2434)
The study aimed to investigate the impact on health care seeking behaviour of the cost-sharing policies introduced in Ghana between 1985 and 1992. Qualitative research techniques were used to investigate the behaviour of patients after the introduction of these policies. Focus group discussions of cohorts of the population and in-depth interviews of health workers and selected opinion leaders were used to collect data from rural and urban health care facilities in three districts of Ghana. The study findings indicate that the cost recovery policies have led to an increase in self-medication and other behaviours aimed at cost-saving. At the same time, there is a perception of an improvement in the drug supply situation and general health delivery in government facilities. The study advocated enhanced training of drug peddlers and attendants at drug stores, especially in rural areas. User fee exemption criteria need to be worked out properly and implemented so that the very needy are not precluded from seeking health care at hospitals and clinics. (+info)