Harvey M. Rappaport

Polypharmacy among Nursing Home Geriatric Medicaid Recipients

OBJECTIVE: To determine the factors that influence the number of different drugs prescribed to geriatric Medicaid recipients residing in Louisianas intermediate care facilities I (ICFs I). DESIGN: Observational and cross-sectional with descriptive and analytic components. PARTICIPANTS: All geriatric Medicaid recipients in Louisiana ICFs I during 1994 (n= 19 932). METHODS: Relevant data on sex, age, race, geographic region of a recipient, number of prescribing physicians, number of pharmacies used, and the number of drugs prescribed to a recipient were extracted from the state Medicaid files. Frequencies for the seven study variables were calculated. Regression analysis was used to evaluate the influence of the six predictor variables on the number of drugs prescribed. RESULTS: The study population was 73.63% women, 60.07% 81 years of age and older, 70.65% white, 23.21% African-American, 6.14% other races, and 29.83% from predominantly rural north Louisiana. A total of 44.60% of the residents received prescriptions from one physician, 8.41% of the residents were single pharmacy users, and 45.65% were prescribed more than 10 drugs during the year. The regression model accounted for 20.53% of the total variation in the number of drugs prescribed to a recipient. Race, geographic region, number of prescribing physicians, and number of pharmacies used by a recipient influenced the number of drugs prescribed. CONCLUSIONS: To reduce the number of drugs prescribed and polypharmacy among geriatric Medicaid recipients, Louisianas ICFs I should minimize the number of physicians and pharmacies used in this population.

Drug information sources used by community pharmacists in Louisiana: a preliminary study.

Objective: There is a paucity of information in the literature regarding the type of reference sources that are used by community pharmacists to answer drug information questions. This survey was conducted to determine the frequency of use of selected drug information references by independent and chain pharmacists in Louisiana. Design: A study population of 15 percent of registered pharmacists was obtained by random stratification of all pharmacists on the mailing list of the Louisiana Board of Pharmacy on the basis of zip code and gender. These pharmacists were mailed an uncoded, pretested questionnaire and were asked to complete and return it if they were employed by an independent or chain pharmacy; nonchain and independent pharmacists were asked to return their questionnaires uncompleted. No follow-up was performed. Participants: Ninety-one independent pharmacists (mean age = 45 y; mean years of experience = 21) and 71 chain pharmacists (mean age = 40 y; mean years of experience = 16). Outcome Measures: The frequency of use of selected drug information reference sources by independent and chain pharmacists and the type of drug information questions received by pharmacists were determined. A Statistical Analysis System software program was used to analyze the data. Spearmans rank test was used to determine statistical differences between independent and chain pharmacists. The a priori level of significance was p≤0.05. Results: A 54 percent response rate was obtained. The frequency of usage of textbook references (Spearmans correlation coefficient [rho]=0.837), journals and periodicals (rho=0.937), and general reference sources (rho=0.943) were similar for independent and chain pharmacists. Drug Facts and Comparisons was the most frequently used reference source. The types of drug information requests that were received by both groups of pharmacists were similar (rho=0.90). Conclusions: Independent and chain pharmacists not only receive the same types of drug information questions but they also rely on the same references to answer such questions. Drug Facts and Comparisons was the most used drug information reference, suggesting that this reference is valuable for pharmacists, particularly community pharmacists.

PIN20 PHYSICIAN PRESCRIBING PATTERNS FOR PEDIATRIC OTITIS MEDIA IN AMBULATORY PATIENTS

call-back for other reasons, to call-back/second prescription. Regardless of the drug prescribed, the utility to the physician of a given outcome is the same. RESULTS: Fewer call-backs and repeat visits pursuant to moxifloxacin resulted in the highest expected value (0.90), compared to levofloxacin (0.89) and Amoxicillin (0.87), when the lowest utility was 0.25. A sensitivity analysis showed consistent results, with 0.86 for Moxifloxacin, 0.85 for Levofloxacin and 0.82 for Amoxicillin when the lowest utility was zero. When the lowest utility was 0.75, all drugs yielded 0.96. CONCLUSION: Physicians who seek to reduce events of call-backs, repeat visits and second prescriptions may favor certain antibiotic regimens, such as Moxifloxacin, for the treatment of acute sinusitis. This is more relevant when physicians put a higher premium on reduced events, that is when the spread in utilities is larger (0.25 and 1.00), than when the spread is smaller (0.75 and 1.00).

A Payment Paradigm for Pharmaceutical Care

2002 April, Volume 36 ■ 721 The implementation of pharmaceutical care is changing the practice of pharmacy. Often the most trusted healthcare professionals, pharmacists have made great strides in changing direction from a drug to a patient orientation. Furthermore, pharmaceutical care appears to be a successful patient-centered paradigm for providing population-based prescription medication management. Yet pharmacists may still be largely unrecognized as medication therapy experts by health systems, other healthcare professionals, patients, and themselves.1 Third-party payers continue to reduce payments for drugs often without corresponding reimbursements for any pharmaceutical care provided. In addition, while still benefiting from the sales of double-digit increases in prescriptions filled, the gross margins of pharmacies are declining as a percentage of sales.2 Yet pharmacists still cling to their economic reliance on reimbursement for the dispensing of a prescription medication. Perhaps more importantly, universal acceptance of economically viable pharmaceutical care continues to evade the profession of pharmacy. Pharmacists are searching for ways to secure that viability. Even the most optimistic data sources, however, only refer to the slow increases in pharmacists charging separate fees for providing disease management services.3 Nevertheless, pharmaceutical care’s continued growth may depend on its ability to survive as a viable economic paradigm. Unless the patient recognizes the value of pharmaceutical care and is willing to pay for it, the pharmacist may be searching in vain. It has been suggested that what is needed is to motivate and create patient and employer demand. In this way, the healthcare market will pay for required and valuable pharmaceutical care services. According to John Gans of the American Pharmaceutical Association, however, we have a problem! “Our current business model does not pay pharmacists to address society’s needs.” Referring to pharmacy’s mission to carry out pharmaceutical care, he states, “Pharmacists . . . are being paid for dispensing prescriptions, not for even the most basic aspects of the services embodied in this mission. We need business models that rely on something other than the margin on a drug product as an incentive to modify the pharmacist’s activities and behavior.”4 Thus, new approaches to paying pharmacists for their professional services may be needed. The basic problem is whether the societal value of pharmaceutical care can be reconciled with the means to pay for it in an already costly prescription drug distribution environment. If not, continued implementation of pharmaceutical care is in danger and may eventually fail. If so, this concept has reached an impasse, a crossroads, and may be unable to progress without changes in the pharmaceutical environment.

STATE PRESCRIPTION LABEL REQUIREMENTS IN THE UNITED STATES

Objective: To determine the current legal requirements for prescription labels and to explore the usefulness of this information in determining the utility of a standardized prescription label. Data Sources: State prescription label regulations were requested from Board of Pharmacy executives. Study Selection: Label requirements for prescriptions dispensed in community, noninstitutional pharmacies were selected for review. Data Extraction: Data were compiled, sorted by state, and analyzed as either federally mandated or additional state requirements. Additional state requirements were divided into 16 categories and analyzed by category. Data Synthesis: Responses were received from all 50 states. Five states did not list all federal label requirements. Medication name was the most frequently added requirement, followed by medication strength and name of manufacturer if the medication was generic. Only in New Jersey are pharmacists allowed to add directions not included in the prescription. Conclusions: States were consistent in the proper use of federal prescription label requirements. However, there was little agreement on what additional information should appear on the label. Nevertheless, there appears to be consensus for the name of the medication to be on the label. There also appears to be fairly strong consensus that medication strength and quantity should appear on the label. There is little interest in expanding the current directions-for-use requirement. Finally, the results support the utility of a standardized prescription label format.