William H. Campbell

Documenting outpatient problem intervention activities of pharmacists in an HMO.

The outpatient drug use review experiences by pharmacists at a large health maintenance organization with on-site pharmacies were investigated. Pharmacists were asked to document the nature of potential drug therapy problems encountered, drug involved, review activities undertaken, and processoutcomes. Patterns of pharmacist intervention were observed over 1 year. Results indicated that the number of problems detected increased substantially during the months immediately following the introduction of problem recording and feedback procedures. During the latter months, the number of prescriptions with problems approximated 4 per 100 dispensed prescriptions. Drug interactions of a moderate nature and drug underuse were the most frequent problem types encountered. Most were not serious and usually resulted in a cautionary or counseling message given to patients by pharmacists. The next most frequently occurring type was drug overuse problems, and, after that, problems concerning some aspect of the prescribing decision. In 9 per cent of all problem interventions and in 44 per cent of prescribing-problem interventions, the outcome of the pharmacist intervention was a change in drug, strength or directions for use. The average amount of pharmacist time per problem intervention varied from 6.0 to 7.8 minutes across problem types. This approximated a pharmacist labor cost of

Measuring the Quality of Medication Use in Older Adults

0.06 per dispensed prescription, given a problem encounter rate of 4 per 100 dispensed prescriptions.

Caregiver psychological distress as a barrier to influenza vaccination among community-dwelling elderly with dementia.

The quality of health care in the United States continues to fall short of expectations. A contributing factor is the suboptimal use of medications, a problem that is causing significant morbidity and mortality and costing the healthcare industry billions of dollars each year. Older adults are especially vulnerable to suboptimal quality medication use because of their concurrent medical conditions, multiple medications, and the physiological effects of aging on the use of drug therapy. In addition, older adults and their caregivers are often responsible for managing complex medication regimens. Efforts to measure the quality of medication use in older adults have traditionally focused on inappropriate medications and doses, select indicators of medication appropriateness, or diseases rather than the unique medication needs of individual patients. The goal is to move toward a measure that can account for the complexities of an individuals medication regimen and that is responsive to individual patient values and needs. The purpose of this article is to discuss the benefits and limitations of current strategies to measure the quality of medication use in older adults and, using a case study, illustrate the variations in quality measurement using existing measures. The article concludes with recommendations for moving toward a more‐comprehensive approach to measuring the quality of medication use in older adults.

Studying the Impact of Patient Drug Profiles in an HMO

Objective:This study examined whether informal caregiver psychologic distress decreases the likelihood of influenza vaccination for community-dwelling elderly with dementia. A secondary aim was to determine whether psychologic distress mediates the relationship between other predisposing, enabling, and medical need variables and vaccination. Methods:Data were drawn from the 1998 National Longitudinal Caregiver Survey. The final sample consisted of 1406 community-dwelling male veterans with dementia and their coresiding female informal caregivers. Presence of caregiver psychologic distress was measured using the Boston Short Form of the Center for Epidemiologic Studies Depression Scale. Vaccination was identified by examining Veteran Administration Outpatient Data Files for visits indicating influenza vaccine administration during the 1998 influenza vaccine season (September 1 to December 31). Multivariate path analysis with observed variables was used to estimate direct and indirect probit path coefficients between independent variables, caregiver psychologic distress, and veteran vaccination. Results:As hypothesized, caregiver distress was significantly associated with a decreased likelihood of care-recipient vaccination (unstandardized coefficient [b] = −0.023, P < 0.01). Adjusted for other variables, the predicted probability of vaccination was 37.7% for care-recipients with nondistressed caregivers compared with 29.4% for care-recipients with distressed caregivers. Furthermore, a number of factors significantly influenced vaccination via their influence on psychologic distress. Conclusion:We conclude that caregiver psychologic distress may interfere with access to influenza vaccination in persons with dementia. Access to vaccination may be improved directly by detecting and treating emotional health problems in caregivers and indirectly by addressing precursors to caregiver distress.

The Quality of Medication Use in Older Adults: Methods of a Longitudinal Study

The objectives of the study were to determine if a drug profile quantitatively and qualitatively influenced various aspects of drug utilization. A group of 1,632 medically indigent persons enrolled in the Kaiser Health Flan constituted the study population. This population received completely prepaid medical care including drug services from the Kaiser Medical Care Program. A computer-based chronological and monthly updated listing of drugs ordered and prescriptions received was provided as the front page of the centralized outpatient medical chart for a randomly selected half of the study population for a full year. Duplicate and bound copies of these patient drug profiles were also provided each outpatient pharmacy. The findings indicated the presence of the drug profile did not quantitatively or qualitatively affect prescription receipt of the group with the profile. Although the findings must be viewed in the contexts of the population served and the medical care setting, the findings strongly indicate the need for additional research to assess additional forms of drug profiles and under conditions not addressed by this study.

Adverse drug reactions in a disadvantaged population

BACKGROUND The quality of medication use in older adults is a recurring problem of substantial concern. Efforts to both measure and improve the quality of medication use often define quality too narrowly and fall short of addressing the complexity of an older adults medication regimen. OBJECTIVES In an effort to more comprehensively define the quality of medication use in older adults, we conducted a prospective cohort study to: (1) describe the quality of medication use in community-dwelling older adults at baseline, examining differences between whites and blacks; (2) examine the effect of race on medication-related problems; and (3) assess the change in quality medication use between whites and blacks over time. This paper presents the research design and methods of this longitudinal study. METHODS We interviewed white and black community-dwelling older adults (aged > or =60 years) 3 times over 1 year (baseline, 6, and 12 months). We oversampled blacks so that we could estimate racial differences in the quality of medication use. We collected information on the quality of medication use, relying on a clinical pharmacists assessment of quality and the Assessing Care of Vulnerable Elders quality indicators. We also collected data on demographic characteristics, health literacy, functional status, and participant-reported drug therapy concerns. RESULTS Four hundred thirty-five older adults were assessed for inclusion; 200 older adults (100 white, 100 black) were enrolled in the study and completed a baseline visit. Of the 200, 92% completed the 6-month visit (n = 183) and 88% completed the 12-month visit (n = 176). We present baseline demographic characteristics for the 200 older adults enrolled in the study. CONCLUSION This longitudinal study is an initial step toward developing more comprehensive, patient-centered measures and interventions to address the quality of medication use in older adults.

Treated adverse effects of drugs in an ambulatory population.

Adverse drug reactions represent an area of concern in the delivery of medical care; most recognized negative indices of health can result from the untoward effects of drug therapy. Current data indicating the nature and extent of the problem are considered to be inadequate for making policy decisions. This study contributes new information about drug reactions in a disadvantaged population, by (1) identifying the nature and the extent of the adverse effects of drugs and (2) estimating the costs for the treatment of these adverse effects.The findings showed that oral contraceptives accounted for almost 26% of the medical care contacts and almost 33% of the estimated costs for treating adverse effects. An incidence rate of approximately 2.3 and a prevalence rate of approximately 2.2 suggest that relatively few persons were treated for the adverse effects of drugs. Costs directly attributable to their treatment, including hospitalization but excluding outpatient drug costs, were estimated to be 44 cents per person per year.Although the adverse effects of drugs did not appear to be a major problem in terms of their occurrence and potential severity for a disadvantaged population and in terms of their economic impact upon a medical care system, more information is needed if strategies for dealing with them are to be efficient and effective.

The Potential Impact of Measuring Healthcare Quality on Pharmaceutical-Related Costs and Outcomes

Adverse drug reactions represent an area of concern in the delivery of medical care. Current data available indicating the nature and extent of the problem of adverse drug reactions are recognized as inadequate for policy making. This study contributes new information about the adverse effects of drugs treated in an outpatient population.The findings showed that the adverse effects of oral contraceptives accounted for a large sharc of medical care contacts, procedures rendered, and estimated dollars espended. The incidence and prevalence rates indicated relatively few persons among the population were treated for adverse effects of dnigs. Annual costs to the medical care system of treating adverse drug effects were estimated to be

Improving communication of drug risks to prevent patient injury: proceedings of a workshop

.83 per person. Additional information is needed about adverse dnig reactions if strategies and approaches to deal with adverse effects of drugs are to be efficient and effective.

Examining Physicians' Drug Order Recording Behavior

Quality measurement has achieved a powerful momentum across the spectrum of healthcare, driven primarily by the search for strategies to contain rapidly rising healthcare costs without sacrificing quality of care. Because pharmaceutical care is involved in almost all elements of healthcare, it is subject to the general impact of quality measurement on the healthcare system as well as quality measurements of pharmaceutical care. The assumption that measuring quality improves the processes and outcomes of care lies behind the drive for quality measurement, but this assumption remains largely untested. Whether the assumption is true depends upon the attributes of measures (importance, perspective, reliability, validity and responsiveness), the quality of the data used, and how and by whom the measures are collected, interpreted and used. Focusing attention on aspects of care that get measured may ‘crowd out’ attention on equally important, but unmeasured elements and may not contribute to allocative efficiency. Successfully turning quality measurement into quality improvement in pharmaceutical care will require two essential elements: continued research to develop, refine and update measures of quality, and education in how to use them.