Patrick D. Meek

Evidence of the economic benefit of clinical pharmacy services: 1996-2000.

We sought to summarize and assess original evaluations of the economic impact of clinical pharmacy services published from 1996–2000, and to provide recommendations and methodologic considerations for future research. A systematic literature search was conducted to identify articles that were then blinded and randomly assigned to reviewers who confirmed inclusion and abstracted key information. Results were compared with those of a similar review of literature published from 1988–1995. In the 59 included articles, the studies were conducted across a variety of practice sites that consisted of hospitals (52%), community pharmacies and clinics (41%), health maintenance organizations (3%), and long‐term or intermediate care facilities (3%). They focused on a broad range of clinical pharmacy services such as general pharmacotherapeutic monitoring (47%), target drug programs (20%), disease management programs (10%), and patient education or cognitive services (10%). Compared with the studies of the previous review, a greater proportion of evaluations were conducted in community pharmacies or clinics, and the types of services evaluated tended to be more comprehensive rather than specialized. Articles were categorized by type of evaluation: 36% were considered outcome analyses, 24% full economic analyses, 17% outcome descriptions, 15% cost and outcome descriptions, and 8% cost analyses. Compared with the studies of the previous review, a greater proportion of studies in the current review used more rigorous study designs. Most studies reported positive financial benefits of the clinical pharmacy service evaluated. In 16 studies, a benefit:cost ratio was reported by the authors or was able to be calculated by the reviewers (these ranged from 1.7:1–17.0:1, median 4.68:1). The body of literature from this 5‐year period provides continued evidence of the economic benefit of clinical pharmacy services. Although the quality of study design has improved, whenever possible, future evaluations of this type should incorporate methodologies that will further enhance the strength of evidence of this literature and the conclusions that may be drawn from it.

Economic Evaluations of Clinical Pharmacy Services—1988–1995

The objectives of this effort were to summarize and critique original economic assessments of clinical pharmacy services published from 1988–1995, and to make recommendations for future work in this area. A literature search was conducted to identify articles that were then blinded and randomly assigned to reviewers to confirm inclusion, abstract information, and assess the quality of study design. The 104 articles fell into four main categories based on type of service described: disease state management (4%), general pharmacotherapeutic monitoring (36%), pharmacokinetic monitoring services (13%), and targeted drug programs (47%). Articles were categorized by type of evaluation; 35% were considered outcome analyses, 32% outcome descriptions, and 18% full economic analyses. A majority (89%) of the studies reviewed described positive financial benefits from the clinical services evaluated; however, many (68%) did not include the input costs of providing the clinical service as part of the evaluation. Studies that were well conducted were most likely to demonstrate positive results. Commonly, results were expressed as net savings or costs avoided for a given time period or per patient. Seven studies expressed results as a benefit:cost ratio (these ranged from 1.08:1 to 75.84:1, mean 16.70:1). Overall this body of literature contains a wealth of information pertinent to the value of the clinical practice of pharmacy. Future economic evaluations of clinical pharmacy services should incorporate sound study design and evaluate practice in alternative settings.

Economic considerations in Alzheimer's disease

Alzheimers disease (AD) is the third most expensive disease in the United States, costing society approximately

Ambulatory Care for Constipation in the United States, 1993 2004

100 billion each year. It is one of the most prevalent illnesses in the elderly population, and with the aging of society, will become even more significant. Costs associated with AD include direct medical costs such as nursing home care, direct nonmedical costs such as in‐home day care, and indirect costs such as lost patient and caregiver productivity. Medical treatment may have economic benefits by slowing the rate of cognitive decline, delaying institutionalization, reducing caregiver hours, and improving quality of life. Pharmacoeconomic evaluations have shown positive results regarding the effect of drug therapy on nursing home placement, cognition, and caregiver time.

Increasing frequency of opioid prescriptions for chronic abdominal pain in US outpatient clinics

OBJECTIVES:Chronic constipation is one of the most common disorders seen in primary care. In order to examine longitudinal changes in the ambulatory care that occur in constipation evaluation and management, we examined national trends in physician office visits associated with constipation between 1993 and 2004.METHODS:Data were derived from the National Ambulatory Medical Care Survey (NAMCS) and the National Hospital Ambulatory Care Survey (NHAMCS) for 1993–2004. Patient visits were classified as encounters for constipation-related care. Analyses were performed by combining 4 yr of data (1993–1996, 1997–2000, and 2001–2004).RESULTS:Ambulatory visits for constipation increased from 4 million (95% CI 3.3–4.7 million) ambulatory visits for constipation annually during 1993–1996 period to 7.95 million (95% CI 6.6–9.4 million) visits during the 2001–2004 period. The proportion of medical visits for constipation increased for pediatricians, but decreased for adult primary care providers from 1993 to 2004. During the observed time period, the proportion of medical visits for constipation did not change for gastroenterologists. The primary treatment for constipation shifted from bulking agents (fiber) to osmotic laxatives.CONCLUSION:There has been a significant increase in physician office visits for constipation between 1993 and 2004, with the highest rate of increase in the pediatric population. Longitudinal trends indicate an increase in constipation-related visits for pediatricians. The primary treatment for constipation among medical providers shifted from using bulking agents to osmotic laxatives for unknown reasons.

Evaluating Prescriptions for the Elderly: Drug/Age Criteria as a Tool to Help Community Pharmacists

BACKGROUND & AIMS Opioids are sometimes used to treat chronic abdominal pain. However, opioid analgesics have not been proven to be an effective treatment for chronic abdominal pain and have been associated with drug misuse, constipation, and worsening abdominal pain. We sought to estimate the national prescribing trends and factors associated with opioid prescribing for chronic abdominal pain. METHODS Chronic abdominal pain-related visits by adults to US outpatient clinics were identified using reason-for-visit codes from the National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey (1997-2008). Data were weighted to produce national estimates of opioid prescriptions over time. Logistic regression analyses, adjusted for complex survey design, were performed to identify factors associated with opioid use. RESULTS The number of outpatient visits for chronic abdominal pain consistently decreased over time from 14.8 million visits (95% confidence interval [CI], 11.6-18.0 visits) in 1997 through 1999 to 12.2 million visits (95% CI, 9.0-15.6 visits) or 1863 visits per 100,000 population in 2006 through 2008 (P for trend = 0.04). Conversely, the adjusted prevalence of visits for which an opioid was prescribed increased from 5.9% (95% CI, 3.5%-8.3%) in 1997 through 1999 to 12.2% (95% CI, 7.5%-17.0%) in 2006 through 2008 (P = 0.03 for trend). Opioid prescriptions were most common among patients aged 25 to 40 years old (odds ratio [OR] 4.6; 95% CI, 1.2-18.4). Opioid prescriptions were less common among uninsured (OR 0.1; 95% CI, 0.04-0.40) and African American (OR 0.3; 95% CI, 0.1-0.9) patients. CONCLUSIONS From 1997 to 2008 opioid prescriptions for chronic abdominal pain more than doubled. Further studies are needed to better understand the reasons for and consequences of this trend.

Transparent and reproducible reports of economic evaluations of clinical pharmacy services: A goal for the future?

OBJECTIVES To use drug/age criteria to determine (1) the prevalence of dispensing of drugs potentially inappropriate for use in elderly patients; (2) the dispensing rate of individual drugs considered potentially inappropriate for use in elderly patients; (3) the association between selected patient characteristics and the prevalence of potentially inappropriate drug dispensing. DESIGN, SETTING, PARTICIPANTS A secondary database of 6,380 new prescription orders dispensed to patients of all ages in ambulatory pharmacies in a mid-western state was used retrospectively for the analysis. A total of 1,530 (23.9%) of the new prescription orders were dispensed to 1,185 elderly patients. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Name, strength, and daily dose of each drug dispensed were compared with drug/age criteria to determine whether a dispensed drug was inappropriate for use in elderly patients. The association of the rate of dispensing of potentially inappropriate drugs with characteristics of the elderly patients, including age, sex, race, number of comorbidities, and prescription drug insurance coverage type, was determined. RESULTS A total of 170 patients (14.3%) were dispensed potentially inappropriate medications. The three most common medications were propoxyphene and propoxyphene combinations, prescription and nonprescription antihistamines, and digoxin at doses > 0.125 mg/day. There was no statistically significant association between inappropriate drug dispensing and patient age, sex, race, number of comorbidities, and prescription drug insurance coverage type. CONCLUSION Pharmacists can use drug/age criteria as a tool for an initial check to assess the appropriateness of drugs used by the elderly. Elderly patients appear equally at risk of using potentially inappropriate medications regardless of demographic, disease, or insurance characteristics.

Defining Minimum Necessary Anticoagulation-Related Communication at Discharge: Consensus of the Care Transitions Task Force of the New York State Anticoagulation Coalition

The recent AJHP article by De Rijdt et al.[1][1] on the economic effects of clinical pharmacy interventions was of particular interest to us.[1][1] Knowing “what works” and what is most effective in health care is crucial for deciding which interventions are the most rational and efficient,[2][2

P-038 Differentiating Oral Mesalamine Adherence Patterns in Ulcerative Colitis Patients: A Group-Based Trajectory Model Approach

BACKGROUND Anticoagulated patients are particularly vulnerable to ADEs when they experience changes in medical acuity, pharmacotherapy, or care setting, and resources guiding care transitions are lacking. The New York State Anticoagulation Coalition convened a task force to develop a consensus list of requisite data elements (RDEs) that should accompany all anticoagulated patients undergoing care transitions. METHODS A multidisciplinary panel of 15 anticoagulation experts voluntarily completed an iterative Delphi process. Resources were disseminated and deliberated via remote technology, with consensus achieved via blinded electronic polling. RESULTS The panel reached consensus on a list of 15 RDEs for anticoagulation communication at discharge (the ACDC List). Consensus was rapidly achieved by the full panel on 13 elements, while 3 (2 of which were combined into 1 element) required multiple iterations and achieved consensus with votes from 8 available panelists. The elements encompassed a range of factors, including drug use and indications, previous exposure and duration of therapy, recent drug exposure and laboratory results and expectations for subsequent administration, therapy goals, patient education and comprehension, and expectations for clinical management. Twelve of the elements are applicable to any anticoagulant, and 3 are specific to warfarin. CONCLUSION The ACDC List identifies specific pieces of clinical information that a panel of anticoagulant experts agree should be communicated to downstream providers for all anticoagulated patients undergoing care transitions. Additional study is needed to objectively evaluate the ability of existing care systems to communicate the elements and to assess possible relationships between communication of the elements and clinical outcomes.

Osteoporosis Screening by Community Pharmacists: Use of National Osteoporosis Foundation Resources

Background:Long-term adherence to mesalamine (5-ASA) is important for the prevention of relapse and for protection against suboptimal outcomes in patients with ulcerative colitis (UC). This study examines the association of baseline covariates with classification into 6 adherence subgroups. Methods:Longitudinal group-based trajectory modeling was used to identify subpopulations of patients with UC (ICD-9 = 556.x) who have similar oral 5-ASA adherence patterns during a 12-month period following an initial oral 5-ASA (index) filling. Monthly adherence was measured using prescription claims from the Truven Health Marketscan Database. Covariates in a multinomial logistic regression model were used to identify significant predictors within each trajectory group. Predictor variables include age, sex, geographic region, rural residence, type of health plan, insurance type, mail-order status, comorbidities, prescription characteristics, and other UC treatments during the 6-month, pre-index period. Results:Initial models show that a 6-group trajectory model best fits the UC data over the 12-month observation period, which demonstrates high measured adherence, complete non-adherence, and 4 intermediate groups that shift across the study period. The most adherent group demonstrates over 80% Proportion of Days Covered (PDC) for each of the 12 months observed, and encompasses 15.3% of the sample. A sizeable group (23.4%) is mostly non-adherent for the study period, with an initial fill and then nearly no refilled prescriptions over the study period (group 6). The smallest group of 9.2% is likely adjusting their medication dosages as they continue to fill their prescriptions throughout the study period (group 3).Characteristics that significantly (P <0.05) differentiate the group with the highest adherence from the group with the lowest adherence (reference group) include age, sex, geographic region, HMO insurance type, mail-order status, 30-day supply, less than a