Mark Jones

Evaluation of Family Physician Prescribing: Influence of the Clinical Pharmacist

This study was designed to determine whether prescribing patterns in family practice residency training offices were more favorable in offices with clinical pharmacists. Two family practice residency training offices with clinical pharmacists and two offices without clinical pharmacists served as study sites. At each office, 100 prescription copies were selected by stratified random sampling, and a case abstract was constructed from the medical record. An additional 38 prescriptions that resulted from clinical pharmacist consultation were studied. A blinded review panel evaluated the cases for appropriateness of drug choice and dose and anticipated benefit of the prescription. Prescriptions from offices with clinical pharmacists and consult prescriptions were rated significantly more favorably both for drug choice and drug dose (p<0.02). These data suggest that clinical pharmacists involved in family practice residency programs may refine and improve otherwise acceptable prescribing.

The effect of d-amphetamine and ephedrine on smoking attitude and behavior.

Using a double blind, randomized, latin square design, 17 light smokers and 6 heavy smokers were given three times per day doses of placebo, 5 mg amphetamine sulfate, 7.5 mg amphetamine sulfate, 25 mg ephedrine hydrochloride or 50 mg ephedrine hydrochloride. Compared to placebo, active drug produced a statistically significant drop in feeling of addiction to cigarettes (p = 0.022). Ephedrine was reported to be more effective than amphetamine (p = 0.046). Subjects reported similar changes in feeling of enjoyment of smoking. Active drug produced a statistically significant drop in the actual amount of tobacco smoked in heavy smokers (p = 0.028), but not in light smokers. Only two smokers were able to quit completely during the experiment, and one of those people resumed smoking after she stopped taking medication. Possible explanations of these findings are discussed.

Capitation payment for pharmacy services. I. Impact on drug use and pharmacist dispensing behavior.

Results of a two-county pilot study in Iowa revealed that capitation may have significant advantages over fee-for-service (FFS) reimbursement in the Medicaid drug program. Consequently, the capitation program was expanded to 32 counties on April 1, 1981 and continued through December 31, 1981. Another 32 counties were used as part of a before: after/experimental: control design. Pharmacists were paid 80% of projected drug expenditures in advance based on the types of Medicaid eligibles who chose them as their providers. The remaining 20% was withheld in an escrow account to be used for supplemental, emergency, and bonus payments. Pharmacists who participated in this experiment were guaranteed that their gross profits on Medicaid prescriptions would remain at least equal to what they would have been if they had remained under the current FFS payment system. Major differences in drug use levels and pharmacist dispensing behavior under capitation financing were observed in the pilot study. However, no such changes associated with payment type were noted in the expanded program. Relative to these findings, a discussion of pharmacist attitudes is presented.

Capitation Payment for Pharmacy Services: II. Impact on Costs

Four areas of cost were analyzed in the expanded capitation drug program: total program costs; drug costs, escrow account distribution, and administrative costs. Total program costs were, on average, 9% higher under capitation. Drug costs, however, were 3% lower than under fee-for-service (FFS) reimbursement. This discrepancy is probably because pharmacists were not at financial risk under the program, the capitation rates were higher than intended, there were many emergency claims, and other aspects of the research environment. Although administrative costs were large, almost two thirds of the development cost was for one-time work, which could be transferred to another state at little or no expense. One third of the total administrative costs can be attributed to complying with regulations of the Health Care Financing Administration. Significant refinement of the present capitation model may be necessary before this financing innovation is used elsewhere. Modifications might include limiting the system to nursing home patients, placing pharmacists at partial financial risk, restricting participation to pharmacies that service a large number of Medicaid eligibles, and basing capitation rates in part on the drug use behavior of cashpaying patients.

Effects of Capitation Payment for Pharmacy Services on Pharmacist-Dispensing and Physician-Prescribing Behavior: I. Prescription Quantity and Dose Analysis

This paper evaluates changes in quantities and appropriateness of dosages and quantities of prescription in capitation and control pharmacies. The data indicate that, under capitation, changes were made in the quantities of ingredients so that the quantities dispensed were significantly different from those prescribed. However, the number of such modifications to prescriptions was small, and the reader is cautioned against drawing broad conclusions. The analysis, then, considers changes in days supply of prescription ingredients during the study period. There were significantly increases in the average days supply of prescription ingredients for maintenance drugs dispensed under the capitation reimbursement scheme; however, no such differences were observed for non-maintenance drugs. Appropriateness of the dosages and quantities of prescriptions were then compared for capitation and fee-for-service pharmacies for the study period, and no significant differences were found. Thus, it is concluded that although capitation was associated with increases in the average days supply of ingredients dispensed for maintenance prescriptions, such changes did not adversely affect the quality of drug therapy as measured by two sets of criteria.

Systemic Adverse Effects from Topical Doxepin Cream

TO THE EDITOR:We report a case of anticholinergic toxicity associated with topically applied doxepin in an elderly man. Case Report. An 80-year-old white male nursing home patient with moderately severe dementia was treated for several months for excoriations on both arms from frequent scratching. No skin rash was evident. Initially, the areas were kept clean and covered with a dressing; however, the scratching continued. Over several months, attempts at management included long-sleeve shirts, gloves, taped arm wraps, and nonmedicated moisturizing lotions. The scratching and excoriations persisted. Considering the scratching as a neurodermatitis and perhaps a manifestation of the patient’s dementia, empiric treatment was begun with haloperidol 1 mg at bedtime. This was discontinued after a two-week trial without benefit. He was then started on carbamazepine 100 mg twice daily, and the dosage was increased to 100 mg in the morning and 200 mg at bedtime after one week. No benefit was seen after three weeks of treatment; therefore, the carbamazepine was discontinued. Additionally, as empiric treatment for possible atopic dermatitis, hydroxyzine 25 mg twice daily for two weeks and loratadine 10 mg/d for five weeks were given in separate trials. The antihistamine therapy produced no changes in the scratching behavior. A trial of acetaminophen was initiated and continued through the time of doxepin therapy; this agent was also ineffective. Therapy with doxepin 5% topical cream was initiated, which was applied to both arms as well as areas on his legs and back three times daily. After two days, the nurses noted the patient was more confused and was yelling. On the third day, he began having difficulty voiding and over the next several days required frequent catheterizations. He also became “thick-tongued.” On day 6 of doxepin therapy, he required treatment for a stool impaction. On day 14 of treatment, the patient began having visual hallucinations, reaching for objects in the air. Doxepin was discontinued at that time. Most of a 30-g tube of doxepin cream had been used. Over the next few days, the patient voided more easily without the need for catheterizations. One week later, the yelling and hallucinations decreased significantly, but persisted. He continued to exhibit some increased confusion compared with that before doxepin was started. Risperidone 0.5 mg at bedtime was initiated. Three weeks later, the nursing staff indicated the patient had returned to his condition prior to initiation of doxepin. The scratching had not diminished over the course of doxepin treatment. The patient’s past medical history included mild chronic obstructive pulmonary disease, type 2 diabetes mellitus, and chronic constipation. Routine medications included glyburide 2.5 mg/d, casanthranol 30 mg with docusate 100 mg, and acetaminophen 650 mg four times daily. He had used an albuterol inhaler, but had not required this in the past two years. Fasting blood glucose during the time he received doxepin was unchanged from previous measurements (103–211 mg/dL). The patient had no history of urinary retention. During the time he was treated for scratching behavior, he twice received courses of sertraline, initiated because of agitation with nursing care, decreasing social interaction, a sad mood, and spending more time in his room. Sertraline was never used concurrently with the previously outlined therapeutic trials and was last discontinued six weeks before the doxepin trial; it also had no effect on his scratching. Discussion.This case represents probable systemic anticholinergic toxicity from topical doxepin administration. 1 Symptoms began on day 2 of therapy; we did not associate doxepin with this reaction until day 14. Symptoms significantly improved over the following weeks. Doxepin has significant antihistaminic properties, and the topical formulation is marketed as an antipruritic. Systemic absorption from topically administered doxepin is well documented. The manufacturer 2 states that serum concentrations from undetectable to 47 ng/mL were found in 19 patients with eczema treated with topical doxepin for eight days. Drake et al. 3 treated 24 adults with acute atopic dermatitis for eight days. On day 8, serum concentrations were undetectable (<5 μg/L) in five patients. In the remaining patients, concentrations varied from 5 to 67 μg/L. The therapeutic serum concentrations of doxepin for depression are 30–150 μg/L. The prescribing information 2,4 for topical doxepin indicates drowsiness as the most common systemic adverse effect. Other possible anticholinergic adverse effects described included dry mouth and emotional changes. Delirium, urinary retention, and constipation are not mentioned. Sedation from topical doxepin has been reported during clinical trials. Additionally, two case reports 5,6 of severe doxepin toxicity in children from topical application have been published. Toxic symptoms with anticholinergic agents may include dry mouth, blurred vision, sinus tachycardia, constipation, urinary retention, and delirium. Our patient demonstrated urinary retention and delirium. He also had a stool impaction during doxepin therapy; however, he had a history of chronic constipation. The nurses’ observation of “thick-tongued” may have represented dry mouth. The patient’s blood pressure and heart rate were never elevated. The patient’s age and dementia may have predisposed him to these reactions. His skin was abraded, which may have enhanced drug absorption. The events described here suggest that topical doxepin was the cause of the hallucinations and aggressive behavior, although we cannot support this with more objective information. Unfortunately, we did not obtain a doxepin concentration during the time our patient was experiencing toxic symptoms. Rechallenge with doxepin was not considered clinically appropriate. The fact that his confusion did not resolve completely after the doxepin is difficult to evaluate because of the unpredictable course of dementia. Possible systemic adverse events must be considered when topical doxepin cream is used. Increased adverse drug reaction monitoring of patients using doxepin cream is recommended.

Book Review: Telephone Medicine

The goal for Telephone Medicine is to provide practical, evidencebased guidelines allowing general internists to effectively incorporate telephone medicine into their practices. Previously published texts on telephone medicine have generally targeted pediatrics. The fact that this text is intended for adult medicine makes it unique. The book is organized into 3 sections. Section 1 reviews the elements of the telephone interview, including a discussion of the benefits and difficulties of telephone medicine and unique skills required. It also discusses the medicolegal aspects of telephone medicine. Section 3 reviews the elements of incorporating telephone medicine into the workplace, including office management issues. Section 2 is the core of the text. It reviews the evaluation and treatment of 17 specific patient complaints. Most topics discussed are common medical complaints, including sore throat, upper respiratory tract infections (URIs), chest pain, dysuria, and headache. The authors should be applauded for including important chapters that are usually less obvious such as domestic violence, the difficult patient, and suicide. Each chapter in Section 2 begins with Key Points that previews the chapter contents and highlights important concepts. The chapters follow a general outline, including questions to ask the patient and a differential diagnosis based on the presenting complaint. The main emphasis of each discussion is to prioritize among patients who might need immediate attention in an emergency department, those that can be seen nonemergently in the office, and those that can be treated without an office visit. Suggestions for nonemergent treatments are provided. Each chapter ends with an algorithm prepared by the authors. The structure of the text does not lend itself to be easily used while the clinician is on the telephone with the patient. The algorithm provides some assistance in this matter, but the text is not easily scanned. Other telephone medicine texts better utilize bulleted lists to help with the telephone encounter. The therapeutic topics are not arranged in the text in any particular order. An alphabetical arrangement or arranging similar topics in consecutive chapters would help the reader locate a section of interest. Section 2 begins with a discussion of chest pain, possibly the most difficult problem to triage over the phone. Helpful evidence is presented regarding various symptoms and their association with a lesser or greater likelihood of myocardial etiology. The evaluation algorithm is rather detailed and not conducive to review while speaking with a patient. However, when digested and understood, the algorithm provides a reasonable thought process for verbally evaluating chest pain. The chapter discussing diarrhea provides a rather detailed and, possibly, esoteric discussion of differential diagnostic considerations, likely unhelpful while taking such calls. Diarrhea, however, is a frequent complaint, and the authors present a fine, concise review of oral rehydration options as well as a helpful list of antidiarrheal medications.