Hospital pharmacists' participation in audit in the United Kingdom.
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OBJECTIVE: To investigate systematically participation in audit of NHS hospital pharmacists in the United Kingdom. DESIGN: Questionnaire census survey. SETTING: All NHS hospital pharmacies in the UK providing clinical pharmacy services. SUBJECTS: 462 hospital pharmacies. MAIN MEASURES: Extent and nature of participation in medical, clinical, and pharmacy audits according to hospital management and teaching status, educational level and specialisation of pharmacists, and perceived availability of resources. RESULTS: 416 questionnaires were returned (response rate 90%). Pharmacists contributed to medical audit in 50% (204/410) of hospitals, pharmacy audit in 27% (108/404), and clinical audit in only 7% (29/404). Many pharmacies (59% (235/399)) were involved in one or more types of audit but few (4%, (15/399)) in all three. Participation increased in medical and pharmacy audits with trust status (medical audit: 57% (65/115) trust hospital v 47% (132/281) non-trust hospital; pharmacy audit: 34% (39/114) v 24% (65/276)) and teaching status (medical audit: 58% (60/104) teaching hospital v 47% (130/279) non-teaching hospital; pharmacy audit 30% (31/104) v 25% (68/273)) and similarly for highly qualified pharmacists (MPhil or PhD, MSc, diplomas) (medical audit: 54% (163/302) with these qualifications v 38% (39/103) without; pharmacy audit: 32% (95/298) v 13% (13/102)) and specialists pharmacists (medical audit: 61% (112/184) specialist v 41% (90/221) non-specialist; pharmacy audit: 37% (67/182) v 19% (41/218)). Pharmacies contributing to medical audit commonly provided financial information on drug use (86% 169/197). Pharmacy audits often concentrated on audit of clinical pharmacy services. CONCLUSION: Pharmacists are beginning to participate in the critical evaluation of health care, mainly in medical audit. (+info)
Ward pharmacy: a foundation for prescribing audit?
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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.
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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)
User fees and drug pricing policies: a study at Harare Central Hospital, Zimbabwe.
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In 1991, Zimbabwe introduced cost recovery measures as part of its programme of economic reforms, following a course taken by many developing countries. The system of user fees in public health care, aimed to 'protect and support the vulnerable groups' by exemption or incremental fees based on 4 income brackets. Drugs were charged at a percentage of the recommended retail price in the private sector. This study of 488 outpatients at a referral hospital in Harare examined how the new fee system functioned 6 months after its introduction. Patients were interviewed and their prescription records examined. Mean charges were determined for each fee category and revenue from drug charges was analyzed in relation to purchase cost to determine the gross profit. 31% of patients were exempted from all fees upon proof of monthly earnings of less than Z$150 (Z$5 = US$1). The remainder were classified into three fee-paying categories. The mean purchase cost for drug items was Z$3.89 per outpatient prescription. Outpatients paid a mean drug charge of Z$9.75 after exemption or discount. This was 2.5 times the cost price. The number of drug items obtained differed according to fee status: the fee-exempt category received a mean of 2.9 drug items compared with 1.9 drug items in the fee-paying categories. This difference originated at the point of prescribing. A number of practical problems in fee collection were noted. The drug pricing system generated high profit even after re-distribution to low-income users. This was attributed to economical and rationalized public sector drug procurement. Observation indicated that a proportion of the vulnerable were not effectively protected due to stringent requirements for proof of income. Appraisal of the fee policy indicated the need for more effective cross-subsidy and better administrative procedures; fee revenue should be directed towards improvement in quality of service. (+info)
Pharmacoeconomic analysis of selected antibiotics in lower respiratory tract infection.
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An interactive pharmacoeconomic model was designed to evaluate the effects of clinical response and adverse drug events on the comparative cost and cost-effectiveness of a relatively new antibiotic, clarithromycin, compared with those of six other antibiotics used to treat community-acquired lower respiratory tract infection. The cost and cost-effectiveness analyses were based don 12 randomized, double-blind, controlled clinical trials conducted between 1987 and 1992 in regionally distributed outpatient clinics in the United States. The trials enrolled a total of 2377 patients. Of the 2377, 1102 patients were treated for acute exacerbation of chronic bronchitis, 591 for pneumonia, and 201 for either of the two conditions. Safety data for one of the antibiotics was obtained from a trial of patients with sinusitis (N = 483). The antibiotics included in the analysis were amoxicillin/clavulanate, ampicillin, cefaclor, cefixime, cefuroxime, clarithromycin, and erythromycin. The main outcome measures were the costs of resources to achieve a clinical response, costs related to managing adverse drug events, and costs of antibiotic treatment from the perspective of managed care. The mean total cost per episode ranged from approximately $137 to $267. The drug acquisition cost typically contributed a small amount to the overall cost. For the cost-effectiveness analysis, in which complication-free cure was used as a proxy for patient satisfaction, the range of mean cost per complication-free cure varied from approximately $307 for clarithromycin to $612 for cefaclor. When ranked from most to least cost-effective, the order was as follows: clarithromycin, cefixime, amoxicillin/clavulanate, erythromycin, cefuroxime, ampicillin, and cefaclor. The costs associated with clinical management (including treatment failure) and managing adverse drug events significantly contribute to the total cost and cost-effectiveness of antibiotics in the outpatient setting. Cost-effectiveness analyses are valuable in analyzing the various costs associated with the treatment of lower respiratory tract infection (acute exacerbation of chronic bronchitis or pneumonia) and may be useful tools for physicians managing patients, members of pharmacy and therapeutics committees developing formularies, and medical staff implementing practice guidelines. (+info)
Development and evaluation of a pharmacist-directed pharmacotherapy center.
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This article is designed for ambulatory pharmacy specialists, pharmacy administrators, and managed care pharmacy and/or medical directors interested in developing systems for improved drug therapy outcomes. GOAL: To describe an alternative method for the effective delivery of pharmaceutical care. OBJECTIVES: 1. Identify the barriers to delivery of pharmaceutical care in current systems. 2. Describe the steps to take to implement a referral-based pharmaceutical care service. 3. Describe the financial and patient satisfaction outcomes of a referral-based pharmacy. 4. Describe the services that can be offered by a referral-based pharmacy. (+info)
Safety and efficacy of metformin in a restricted formulary.
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OBJECTIVE: To assess the efficacy and safety of metformin (MET) in the Veterans' Administration Northern California Health Care System during the period from June 1995 through April 1996 when its use required approval by Endocrinology. STUDY DESIGN: A retrospective review of patient charts and computerized pharmacy and laboratory records. Patients served as their own historical controls. PATIENTS AND METHODS: Patients receiving MET (n = 251) were identified from the pharmacy database. On-line laboratory data, including the intermediate outcome variable HbA1c, were retrieved by computer for the interval 4 months prior to the initial prescription to May 1996. Clinical data including weight and blood pressure were obtained from chart review. RESULTS: Of 228 patients whose charts were available for review, 29 reported side effects, and 12 discontinued use due to these side effects. No patients were identified with lactic acidosis. Both baseline and treatment data on HbA1c were available on 164 patients. Mean HbA1c (%) data (unpaired), expressed as mean +/- SE, were as follows: between 4 months pretreatment and 1 month pretreatment, 9.41 +/- 0.19 (n = 103 tests); between 1 month pretreatment and baseline, 9.41 +/- 0.19 (n = 110 tests); 3 months of treatment, 8.79 +/- 0.16 (n = 157 tests, P < 0.05); 6 months of treatment, 8.30 +/- 0.17 (n = 79 tests, P < 0.0001); 9 months of treatment, 8.72 +/- 0.24 (n = 70 tests, P < 0.05), compared to pretreatment values. Similar analysis of unpaired weight and blood pressure data in 152 patients did not reveal any reduction in these clinical parameters over this treatment period. Serum lipids were unchanged on treatment (by paired analysis), but the number of tests was limited. CONCLUSION: In this setting, MET provided sustained beneficial effects on glycemic control and was well tolerated. Any effects on weight, blood pressure, and serum lipids were not demonstrable in this analysis. We conclude that MET can substantially improve outcome of diabetes care. (+info)
Impact of therapeutic interchange from pravastatin to lovastatin in a Veterans Affairs Medical Center.
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OBJECTIVE: To evaluate the impact of a therapeutic interchange from pravastatin to lovastatin on treatment outcomes, quality of life, patient satisfaction, and costs. STUDY DESIGN: A prospective cohort study of 170 patients switched from pravastatin to lovastatin from September 1997 through November 1997. PATIENTS AND METHODS: The therapeutic interchange program promoting lovastatin as the preferred agent went into effect June 2, 1997 after Merck & Co. was awarded the Veterans Health Administration national contract for 3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitors. Patients were switched to lovastatin by either their primary care physician during routine clinic visits or the pharmacist by mail. The following outcomes were measured before and after conversion to lovastatin: lipid values, liver function tests, National Cholesterol Education Program (NCEP) low-density cholesterol (LDL-C) goals achieved, quality of life (QOL) (measured by the Medical Outcomes Study 36-item short-form health survey [SF-36]), medication tolerance (measured with a global symptom survey), patient satisfaction, and cost-minimization analysis. RESULTS: Lipid values and liver function test results were similar for pravastatin and lovastatin treatment. Forty percent of patients achieved NCEP LDL-C goals before and after formulary conversion. There were no significant differences between pravastatin and lovastatin in QOL, medication tolerance, and patient satisfaction. The projected cost savings from this therapeutic interchange was approximately $211,000 annually. CONCLUSION: Therapeutic interchange from pravastatin to lovastatin resulted in substantial cost savings. QOL, patient satisfaction, and achievement of NCEP LDL-C goals were maintained. (+info)