Helene Levens Lipton

Popular films do not reflect current tobacco use.

This study examined trends in tobacco use in a random sample of 2 of the 20 top-grossing US films each year from 1960 through 1990 (62 films). The overall rate of tobacco use did not change. Films continue to portray smokers as successful, attractive White males. Smoking groups became larger, smoking alone declined, hostility and stress reduction were increasingly associated with smoking, and smoking by minor characters increased. Although smoking among elite characters fell, it remained nearly three times as prevalent as in actual population data during the 3 decades. Events involving young people more than doubled. Films do not accurately represent smoking in the United States.

Characterization of geriatric drug-related hospital readmissions.

Although some factors placing geriatric patients at risk for hospitalization have been identified, little is known about drug-related problems that contribute to admissions. This study describes a protocol for characterizing drug-related problems that are associated with hospital readmissions. The protocol achieves significant improvements over other studies because geriatric readmissions to a community hospital are classified and the type of drug-related problem and relative contribution of the problem to the readmission are assessed. Thirty-five percent of study patients (n=706) were readmitted within 6 months of their former discharge and 45 of the readmissions were drug-related. The assessments of three reviewers working independently agreed for 82% of the readmissions (kappa=0.64). Eighteen percent of the cases identified as drug-related using the protocol were also classified as drug-related according to the hospital ICD-9 coding procedure. One percent of the readmissions classified according to the protocol as not drug-related received ICD-9 codes indicating drug-related problems. These findings suggest that the protocol identified drug-related hospital readmissions with good reliability and sensitivity. The most frequently identified drug-related problems were unexpected adverse drug reactions (n=10), patient noncompliance (10), overdose (8), lack of a necessary drug therapy (6) and underdose (5). Drug-related factors were a major reason, rather than a contributory reason, for readmission in half of the cases. The study identifies specific drug-related problems that could become targets for preventive interventions. The majority (76%) of the problems identified were potentially preventable and the types of problems found indicate that interventions should be focused on both physicians and patients.

Drug utilization review in ambulatory settings: state of the science and directions for outcomes research.

There are escalating national pressures to analyze pharmaceutical outcomes and to develop drug-related clinical guidelines. These interests coincide with passage of the Medicaid Rebate Law (OBRA, 1990), which mandates the implementation of prospective and retrospective drug utilization review (DUR) programs by Medicaid in 1993. This report investigates DUR programs that target outpatient drug therapies. The authors present a conceptual framework that identifies the factors influencing drug prescribing and the range of potential patient outcomes. Current types of DUR interventions and their applications are described, in addition to problems that hinder implementation or evaluation of DUR programs. DUR evaluation studies are reviewed, and a critique identifies the limitations of available DUR research. The authors recommend an expanded DUR policy research agenda, strongly suggesting that priority be given to studies in the following areas: DUR criteria development and validation; prevalence of prescribing problems and their association with patient outcomes; efficacy, toxicity and costs of therapeutic alternatives; and DUR program evaluation. The overall conclusion is that the state of the science pertaining to DUR is not well developed. The potential of DUR may not be realized due to the lack of resources needed to design, implement, and evaluate effective programs. Instead, DUR efforts may be limited to cost-containment issues without due consideration of quality-of-care outcomes. The authors call for rigorous evaluation efforts to inform DUR design and implementation, thereby assuring more rational prescribing and enhancing patient outcomes.

The Effect of Cyclosporine on the Use of Hospital Resources for Kidney Transplantation

Over the past decade the clinical results of kidney transplantation have improved substantially, with much of the benefit being attributed to the introduction in late 1983 of the immunosuppressive drug cyclosporine. To assess the effect of cyclosporine on the use of hospital services, we studied 702 patients who received kidney transplants at the University of California, San Francisco, between July 1982 and June 1986. All services were priced in constant 1985 dollars, and multiple regression analysis was used to adjust for changing patient and hospital characteristics. The introduction of cyclosporine for patients receiving kidneys from cadavers was associated with a significantly shorter adjusted mean postoperative stay (26.4 days as compared with 37.0 for patients not taking the drug; P less than 0.0001) and lower adjusted mean hospital charges (

Drug utilization review: State of the art from an academic perspective

28,649 as compared with

Promoting access and reducing expected out-of-pocket prescription drug costs for vulnerable Medicare beneficiaries: a pharmacist-directed model.

37,895; P less than 0.0001), although cyclosporine was not associated with changes in the use of services by patients who received transplants from living related donors. Cyclosporine was also associated with a reduction in the use of certain ancillary services, such as laboratory tests and radiographic procedures. In patients without diabetes who received cadaver kidneys, a sequential cyclosporine regimen (in which a combination of antilymphoblast globulin, prednisone, and azathioprine was given before cyclosporine) reduced the use of hospital services even more than did a cyclosporine regimen in which the combination was not given. The results suggest that new medications, such as cyclosporine, that reduce the frequency of complications and improve outcomes may also reduce the use of hospital resources.

Pharmacists and health reform: go for it!

Clinical Pharmacology and Therapeutics (1991) 50, 616–619; doi:10.1038/clpt.1991.194

Do-Not-Resuscitate Decisions in a Community Hospital: Implications for Quality Care

BackgroundThe Medicare Part D benefit is complicated and may be costly, especially for vulnerable low-income populations where lack of resources and limited English proficiency may be barriers to optimal plan selection. ObjectivesTo identify vulnerable Medicare beneficiaries and lower their expected annual out-of-pocket (OOP) prescription drug costs through one-on-one prescription drug plan counseling by pharmacists and trained pharmacy students. Research DesignBetween October 2008 and January 2010, a cross-sectional study was performed throughout California. Using Medicares Prescription Drug Plan Finder tool, expected annual OOP costs for each beneficiarys current prescription drug plan were compared with the lowest-cost plan. SubjectsThe study sample included vulnerable Medicare beneficiaries with annual incomes ⩽300% of the Federal Poverty Level. ResultsThere were 1300 vulnerable beneficiaries who received counseling at 94 outreach events. Only 29% of beneficiaries with a stand-alone Part D prescription drug plan were enrolled in the lowest-cost plan. On the basis of counseling recommendations, 390 beneficiaries changed to the lowest-cost Part D plan on site, reducing their expected OOP costs by 68%. Additionally, 72 beneficiaries were identified as eligible for but not receiving low-income subsidy benefits and 55 received assistance with the online application for the subsidy. ConclusionsFindings show that targeted outreach by trained pharmacy advocates can identify vulnerable Medicare populations in need of Part D counseling and reduce their expected annual OOP prescription drug costs.

Managing the unmanageable: the nature and impact of drug risk in physician groups.

Now is the time for the profession of pharmacy to reach out, speak out, and act out to assume leadership under health reform. The opportunities today are unprecedented for pharmacists. The March 23, 2010, Patient Protection and Affordable Care Act, and the regulations surrounding it that are being written, offer powerful venues to demonstrate the full breadth of the profession’s capacity for promoting the nation’s health. But the profession must act now or lose an historic chance to become inextricably woven into the fabric of our nation’s health reform mandate. This editorial will explore the major pharmacistrelated provisions of the health reform law, the opportunities that the law presents for pharmacists, and specific strategies that pharmacists and their advocates can use to expand pharmacists’ roles under health reform.

Panel IV. Evaluation: The value and cost-effectiveness of drug utilization review programs*

The appropriateness of medical care provided to patients after DNR designation was analyzed in a 450-bed community hospital. All 333 patients who received written DNR orders in a six-month period were studied. Appropriateness of care was assessed by three physician consultants, each of whom independently reviewed a case abstract prepared for every patient. In 95% of the cases, care after DNR designation was judged appropriate relative to the patients diagnosis and prognosis. Care was judged inadequate in 1 case and overly aggressive in 17 cases. These findings suggest that the DNR decision does not lead to medical abandonment of the patient and that the expensive and invasive medical care resources are not being allocated inappropriately in the vast majority of DNR patients.