Thomas K. Hazlet

Global epidemiology of hepatitis B virus.

The burden of hepatitis B virus (HBV) disease and efforts to control infection will determine the future size of the population requiring treatment of HBV infection. To quantify the current prevalence of HBV infection and to reexamine the epidemiology of HBV infection, a structured review was conducted that focused on available primary literature for over 30 countries worldwide. The prevalence of chronic HBV infection continues to be highly variable, ranging over 10% in some Asian and Western Pacific countries to under 0.5% in the United States and northern European countries. The current global estimate of the number of HBV infected individuals is 350 million. Routes of transmission include vertical (mother to child or generation to generation through close contact and sanitary habits), early life horizontal transmission (through bites, lesions, and sanitary habits), and adult horizontal transmission (through sexual contact, intravenous drug use, and medical procedure exposure) and are evident to varying degrees in every country. Younger age at acquisition of infection continues to be the most important predictor of chronic carriage. However, the choice of serologic markers, temporal influences, and representativeness of the study population limit comparability of HBV seroprevalence results. HBV vaccination programs will decrease the future global burden of HBV infection and evidence of reduced burden is mounting in country-specific populations, but vaccination programs have still not been implemented in all countries, thereby maintaining reservoirs of infection and continued HBV transmission. Regardless of vaccination, large numbers of persons are infected with HBVor will become infected. Preventing the most severe HBV disease consequences in infected individuals, such as cirrhosis and hepatocellular carcinoma, will require appropriate therapeutic agents.

Performance of community pharmacy drug interaction software.

OBJECTIVE To evaluate the performance of computerized drug-drug interaction (DDI) software in identifying clinically important drug-drug interactions. DESIGN One-time performance test of computer systems using a standard set of prescriptions. SETTING Community pharmacies or central corporate locations with pharmacy terminals identical to those used in actual pharmacies. PARTICIPANTS Chain and health maintenance organization (HMO) pharmacies with seven or more practice sites in Washington State. A total of nine different DDI software programs were installed in 516 community pharmacies represented by these chains and HMOs. MAIN OUTCOME MEASURES Sensitivity, specificity, and positive and negative predictive values of software in detecting 16 well-established DDIs contained within six fictitious patient profiles. RESULTS The software systems failed to detect clinically relevant DDIs one-third of the time. Sensitivity of the software programs ranged from 0.44 to 0.88, with 1.00 being perfect; specificity ranged from 0.71 to 1.00; positive predictive value ranged from 0.67 to 1.00; and negative predictive value ranged from 0.69 to 0.90. For software packages that were installed at different locations, between-installation differences were observed. CONCLUSION The performance of most DDI-detecting software programs tested in this study was suboptimal. Improvement is needed to advance their contribution to detection of DDIs.

Health services utilization with reference drug pricing of Histamine2 receptor antagonists in British columbia elderly

Background. In October 1995, British Columbia introduced a reference pricing policy for five therapeutic classes of drugs, including histamine2 receptor antagonists (H2RAs), for beneficiaries of its prescription drug program, Pharmacare. Objectives. To evaluate utilization trends in consumption of health services in a cohort of Pharmacare beneficiaries to determine if a worsening of health outcomes could be detected after implementation of the reference pricing policy. Research Design. Two cohorts, “control” (21 months before the reference pricing policy) and “exposed” (at risk for policy effects), were followed for 21 months. Using a longitudinal generalized linear model (Poisson), and controlling for age, sex, and prescriptions in unique drug classes, trend lines in each of these time series were compared for 3 periods: 9 months before policy implementation (or corresponding index date in the control cohort), 6 months after policy implementation, and a subsequent 6-month period. Subjects. Two cohorts, each of size 10,000, were constructed by randomly sampling the population of Pharmacare beneficiaries exposed to H2RAs and other antisecretory drugs for 1993 through 1996. Measures. Prescriptions, physician office visits and associated transactions (ie, laboratory tests), emergency room visits, hospitalizations, hospital length of stay, and vital statistics. Results. Differences between periods and between cohorts for health services utilization were not significant or decreased after imposition of the reference pricing policy. Conclusion. For these measures, there has been no worsening of health outcomes associated with implementing the reference pricing policy.

Professional Organizations and Healthcare Industry Support: Ethical Conflict?

A good deal of attention has been recently focused on the presumed advertising excesses of the healthcare industry in its promotion techniques to healthcare professionals, whether through offering gratuities such as gifts, honoraria, or travel support 2-6 or through deception. Two basic concerns have been expressed: Does the acceptance of gratuities bias the recipient, tainting his or her responsibilities as the patients agent? Does acceptance of the gratuity by the healthcare professional contribute to the high cost of healthcare products? The California Society of Hospital Pharmacists was recently asked by its members to formulate a policy for an appropriate relationship between the Society and the healthcare industry, addressing these concerns. In formulating its policy, it became clear that the Society depended on healthcare industry support, gathered through journal advertising, fees for booths at its various educational events, and grants for speakers.

Probiotics for neonates: safety for prime time questioned without regulatory changes.

Purpose: Necrotizing enterocolitis (NEC) is the most common acquired disease of the gastrointestinal tract in preterm infants, whereas probiotic supplementation might reduce NEC risk and potentially provide benefits to preterm infants. We performed an updated meta-analysis of all relevant randomized, controlled trials to assess the benefits of probiotic supplementation for preterm very low-birth-weight (VLBW) infants. Methods:We searched in PubMed, Embase, and Chinese BioMedical Literature Database (CBM) databases, and 20 randomized, controlled trials (a total of 3816 preterm VLBW infants) were finally included into this meta-analysis. Incidence and relative risk (RR) were calculated using a random-effects or fixed-effects model depending on the heterogeneity of the included studies. Results: Probiotic supplement was associated with a significantly decreased risk of NEC in preterm VLBW infants (RR = 0.33; 95% confidence interval [CI], 0.24-0.46; P < .00001). Risk of death was also significantly reduced in the probiotic group (RR = 0.56; 95% CI, 0.43-0.73; P < .0001). There was no difference in the risk of sepsis between the probiotic group and placebo group (RR = 0.90; 95% CI, 0.71-1.15; P = .40) Conclusions: Probiotic supplement can reduce risk of NEC and mortality in preterm VLBW infants. However, the optimum type of probiotic supplement and the long-term effects need further study.

Generic medication utilization policies in the United States and Medicaid sustainability

Our goal was to describe the history and expansion of generic drug utilization policies and their critical role in the US Medicaid system in an era of budget depletion.