Dale B. Christensen

Alprazolam as an Alternative to Low‐Dose Haloperidol in Older, Cognitively Impaired Nursing Facility Patients

OBJECTIVES: To determine if alprazolam is equally as effective as low dose haloperidol in managing disruptive behavioral episodes associated with delirium, dementia, and amnesic and other cognitive disorders (formerly called organic mental syndromes).

Comparison of Prescription and Medical Records in Reflecting Patient Antihypertensive Drug Therapy

OBJECTIVE: To determine the completeness of prescription records, and the extent to which they agreed with medical record drug entries for antihypertensive medications. SETTING: Three clinics affiliated with two staff model health maintenance organizations (HMOs). PARTICIPANTS: Randomly selected HMO enrollees (n=982) with diagnosed hypertension. METHODS: Computer-based prescription records for antihypertensive medications were reviewed at each location using an algorithm to convert the directions-for-use codes into an amount to be consumed per day (prescribed daily dosage). The medical record was analyzed similarly for the presence of drug notations and directions for use. RESULTS: There was a high level of agreement between the medical record and prescription file with respect to identifying the drug prescribed by drug name. Between 5 and 14 percent of medical record drug entries did not have corresponding prescription records, probably reflecting patient decisions not to have prescriptions filled at HMO-affiliated pharmacies or at all. Further, 5–8 percent of dispensed prescription records did not have corresponding medical record drug entry notations, probably reflecting incomplete recording of drug information on the medical record. The percentage of agreement of medical records on dosage ranged from 68 to 70 percent across two sites. Approximately 14 percent of drug records at one location and 21 percent of records at the other had nonmatching dosage information, probably reflecting dosage changes noted on the medical record but not reflected on pharmacy records. CONCLUSIONS: In the sites studied, dispensed prescription records reasonably reflect chart drug entries for drug name, but not necessarily dosage.

Effect of high altitude on blood glucose meter performance.

Participation in high-altitude wilderness activities may expose persons to extreme environmental conditions, and for those with diabetes mellitus, euglycemia is important to ensure safe travel. We conducted a field assessment of the precision and accuracy of seven commonly used blood glucose meters while mountaineering on Mount Rainier, located in Washington State (elevation 14,410 ft). At various elevations each climber-subject used the randomly assigned device to measure the glucose level of capillary blood and three different concentrations of standardized control solutions, and a venous sample was also collected for later glucose analysis. Ordinary least squares regression was used to assess the effect of elevation and of other environmental potential covariates on the precision and accuracy of blood glucose meters. Elevation affects glucometer precision (p = 0.08), but becomes less significant (p = 0.21) when adjusted for temperature and relative humidity. The overall effect of elevation was to underestimate glucose levels by approximately 1-2% (unadjusted) for each 1,000 ft gain in elevation. Blood glucose meter accuracy was affected by elevation (p = 0.03), temperature (p < 0.01), and relative humidity (p = 0.04) after adjustment for the other variables. The interaction between elevation and relative humidity had a meaningful but not statistically significant effect on accuracy (p = 0.07). Thus, elevation, temperature, and relative humidity affect blood glucose meter performance, and elevated glucose levels are more greatly underestimated at higher elevations. Further research will help to identify which blood glucose meters are best suited for specific environments.

Nonmedical factors associated with the prescribing volume among family practitioners in an HMO.

The influence of selected variables on the prescribing volume of eighty family practitioners in a large HMO was quantified through multiple regression analysis. Over 70% of the variation was explained. The patient panel size and age composition were the most important determinants and accounted for 45.7% of the variance. The number of patients seen per clinic hour explained 14.3% and interclinic differences explained another 8.1% of the variance. Further, the data indicated two processes that might have affected results of earlier studies. First, female patients tend to select female physicians, as indicated by a high correlation between the sex of a physician and the proportion of females in the panels. Second, older physicians tend to have older patients. This implies that physician age does not explain higher prescribing rates, but is merely a proxy for older panels of patients who generally have more chronic illnesses and need more drugs.

Drug prescribing: Patterns, problems and proposals

Abstract The focus of this paper is on physicians as gatekeepers to public access to prescribed drugs. Variations in drug prescription and consumption are examined and the factors associated with varying factors of prescribing are discussed. We look at models of the prescribing process and assess their comparative merits. The paper concludes with a consideration of the priorities that need to be taken into account when planning future research of which nine possible key questions are proposed.

A Comparison of Patient Drug Regimens as Viewed by the Physician, Pharmacist and Patient

This study sought to determine the completeness and congruence of records for drugs ordered and received by outpatients. The setting was a large outpatient medical facility that was part of a large multispecialty hospital. It was found that a listing of current drug orders (prepared by physicians) and a listing of current prescription drugs consumed (prepared from pharmacy drug profiles) each agreed 73 per cent of the time with a list of 107 prescription drugs actually consumed by 26 study patients. Lists were compared based on drug name, strength and directions for use. Further, the physician and pharmacy lists correlated with one another 70 per cent of the time, indicating a substantial degree of inconsistent as well as incomplete drug records within the same setting. In another comparison involving medical chart drug notations and pharmacy drug profiles, a complete match or drug name, strength and directions for use occurred in 39 per cent of the cases, while a match on drug name only occurred 64 per cent of the time. The highest degree of congruence occurred between hospital discharge medication notes and outpatient drug profile records. Based on the results of this study, the common assumption that drug records in such settings are congruent and complete appears unwarranted.

Documenting outpatient problem intervention activities of pharmacists in an HMO.

The outpatient drug use review experiences by pharmacists at a large health maintenance organization with on-site pharmacies were investigated. Pharmacists were asked to document the nature of potential drug therapy problems encountered, drug involved, review activities undertaken, and processoutcomes. Patterns of pharmacist intervention were observed over 1 year. Results indicated that the number of problems detected increased substantially during the months immediately following the introduction of problem recording and feedback procedures. During the latter months, the number of prescriptions with problems approximated 4 per 100 dispensed prescriptions. Drug interactions of a moderate nature and drug underuse were the most frequent problem types encountered. Most were not serious and usually resulted in a cautionary or counseling message given to patients by pharmacists. The next most frequently occurring type was drug overuse problems, and, after that, problems concerning some aspect of the prescribing decision. In 9 per cent of all problem interventions and in 44 per cent of prescribing-problem interventions, the outcome of the pharmacist intervention was a change in drug, strength or directions for use. The average amount of pharmacist time per problem intervention varied from 6.0 to 7.8 minutes across problem types. This approximated a pharmacist labor cost of

Characteristics of Pharmacies and Pharmacists Associated with the Provision of Cognitive Service in the Community Setting

0.06 per dispensed prescription, given a problem encounter rate of 4 per 100 dispensed prescriptions.

A randomized controlled trial of a drug use review intervention for sedative hypnotic medications.

OBJECTIVE To determine the influence of payment, pharmacy setting characteristics, pharmacist demographics, practice setting, and attitudinal characteristics on whether cognitive services (CS) were performed by pharmacists, and the volume of CS performed. DESIGN Prospective randomized trial. Community pharmacies were randomized to a documentation-and-payment group (study group) and a documentation-only group (control). Participating pharmacies and pharmacists were surveyed by mail, and responses were linked to a documented CS database. SETTING Community pharmacies serving ambulatory Medicaid patients in the state of Washington, excluding health maintenance organization pharmacies and pharmacies predominantly serving long-term care residents. PARTICIPANTS 200 community pharmacies and their pharmacists (110 study, 90 control) participating in the Washington State Cognitive Activities and Reimbursement Effectiveness (CARE) Project. INTERVENTION Payment for CS. All participants documented CS. Study group pharmacies billed Medicaid for services performed in identifying and resolving drug therapy-related problems. MAIN OUTCOME MEASURE Documentation of CS. RESULTS Documentation of CS was more likely if the pharmacist was an owner or manager, if documentation was not perceived as burdensome, and if the pharmacy had a low ratio of prescription to total sales. Higher documentation rates were associated with study group status, lower pharmacy prescription volume as a percentage of total sales, and a higher percentage of prescriptions billed to Medicaid. Among pharmacists, two setting variables--medical center location and rural location--were associated with higher documentation rates. CONCLUSION Performance of CS was strongly affected by payment and other situational factors, including practice setting and volume of prescriptions dispensed. Pharmacies and pharmacists were also more likely to perform CS if the target patient population represented a relatively large percentage of that pharmacys patient clientele.

Sources of information and influence on new drug prescribing among physicians in an HMO.

OBJECTIVES Drug use review is used by both the public and private sector to influence prescribing behavior and patient drug use. Past interventions mailed to prescribers have had mixed results. The objective was to evaluate the effect of a one-time, mailed intervention on subsequent use of sedative hypnotic medication. METHODS An experimental design was used. The intervention contained guidelines for the use of sedative hypnotics, a prescriber profile detailing sedative hypnotic prescribing, and a patient profile. Clustering of patients and their shared prescribers was done to avoid contamination bias and statistical problems associated with a lack of independence of observations. Subjects were 189 Washington State Medicaid recipients who had received at least one tablet per day of a sedative hypnotic medication for 1 year and their prescribing physicians or (when information about the physician was lacking) the dispensing pharmacy. RESULTS A significant reduction in the use of targeted sedative hypnotic medications was measured in the intervention group (-27.6%) versus the control group (-8.5%). In the intervention group, 9.4% of patients began a new prescription for a benzodiazepine not targeted by the drug use review, whereas no control patients had new use of nontarget benzodiazepines. CONCLUSIONS The intervention achieved a statistically significant decrease in targeted drug use, and the amount of reduction is likely to have decreased the risk of fractures associated with benzodiazepine use. This study adds to the recent evidence that mailed drug use review interventions can have a desirable impact on patient drug use.