Drug utilization review in an HMO. I. Introduction and examples of methodology

The patient's role in the spread and control of bacterial resistance to antibiotics

As the ultimate consumers, patients play an important role in the emergence, spread and control of bacterial resistance to antibiotics. Improved knowledge of antibiotics and the problem of resistance, as well as a better understanding of beliefs, pressures/concerns, and expectations, from both the patient's and physician's perspectives, are fundamental for controlling antibiotic use. There is growing evidence to suggest that empowering patients through implementation of patient-centered health-care strategies, such as shared decision-making, in conjunction with educational initiatives help to change attitudes and behavior, and improve access to and completion of appropriate antimicrobial therapy. This, in turn, may help to control the development and spread of resistance to antibiotics.

Positive impact of a follow-up phone call to community pharmacies in a medicaid drug utilization program

OBJECTIVE

To evaluate the impact of including community pharmacists in strategies to alter excessive prescribing of antiulcer medications (AUMs) in a statewide drug utilization review (DUR) program. Mailing educational materials to physicians is a common intervention strategy of retrospective DUR programs. However, pharmacists are typically left out of this process, ignoring a possibly influential healthcare provider.

METHODOLOGY

Patients without gastroesophageal reflux disease who received > or = 1.0 normalized therapeutic equivalents (e.g., 1.0 NTE = ranitidine 300 mg/d or omeprazole 20 mg/d) for five of six prior months were included. The pharmacists and physicians of these patients were divided into one of three geographically distinct groups: group 1 physicians received mailed materials only (pharmacists were not contacted); group 2 physicians and pharmacists received mailed materials only; and group 3 physicians and pharmacists received mailed materials, and the pharmacists were contacted by phone. Mean NTE and AUM costs were analyzed six months before and six months following the intervention.

RESULTS

One hundred thirty-eight, 329, and 248 patients were included in G1, G2, and G3, respectively. There was a 12.4%, 8.0%, and 14.0% reduction in NTE for G1, G2, and G3, respectively. G1 AUM cost decreased 7.7% ($7710); G2 decreased 6.8% ($14 037); G3 decreased 20.5% ($26722). The total decrease in AUM cost for the entire cohort from before to after the intervention was $48469 (p < 0.05) in the six months following the intervention.

CONCLUSIONS

A follow-up phone call to pharmacists in a statewide DUR intervention enhances the effectiveness of DUR interventions under the conditions studied. Enlisting the support of community pharmacists may improve the cost savings of these interventions.

A computerized intervention to decrease the use of calcium channel blockers in hypertension

OBJECTIVE

To determine whether a computer-assisted reminder would alter prescribing habits for the treatment of hypertension in accordance with current clinical guidelines in a general internal medicine clinic.

DESIGN

A randomized trial.

SETTING

The General Internal Medicine Clinic of the Veterans Affairs Puget Sound Health Care System, Seattle Division.

PATIENTS/PARTICIPANTS

Clinic providers were randomized to a control group (n = 35) or intervention group (n = 36). We targeted the providers of patients being treated for hypertension with calcium channel blockers, a class of drug not recommended for initial therapy.

INTERVENTION

An automated computer query identified eligible patients and their providers. A guideline reminder was placed in the charts of patients of intervention providers; the charts of patients of control providers received no reminder.

MEASUREMENTS AND MAIN RESULTS

During the 5-month study period, 346 patients were seen by the 36 primary care providers (staff physicians, nurse practitioners, residents, and fellows) in the intervention group, and 373 patients were seen by the 35 providers in the control group. Intervention providers changed 39 patients (11.3%) to other medications during the study period, compared with 1 patient (<1.0%) of control providers (p < .0001). For patients whose therapy was unchanged, providers noted angina in 23.1%, indications other than those for hypertension in 9.5%, intolerable adverse effects with first-line therapy in 13.9%, and inadequate control with first-line therapy in 13.9%. Of those patients without provider-indicated contraindications, 23.6% were switched from calcium channel blockers to first-line agents during the intervention period.

CONCLUSIONS

The use of a computerized, clinic-based intervention increased compliance with guidelines in the treatment of primary hypertension in general, and decreased the use of calcium channel blockers for the treatment of hypertension in particular.

Medicines and culture--a double perspective on drug utilization in a developing country

A double perspective, one medical-pharmacological and one social-anthropological, is used to understand the logic of drug utilization among practitioners and outpatients at a health unit in Sri Lanka. Both negative and positive aspects of local prescribing practices are highlighted. Western pharmaceuticals are integrated into therapeutic choices for outpatients in Sri Lanka by means of the Ayurvedic theory of balance and practitioners' and patients' behaviour in consultations results in their expectations being met, even if they do not use the same set of health ideas and interpretations of health intervention. The healing power ascribed to Western pharmaceuticals is described and their possible risks discussed from both a biomedical and an anthropological point of view.

A model of methods for influencing prescribing: Part I. A review of prescribing models, persuasion theories, and administrative and educational methods

The purpose of this literature review is to develop a model of methods to be used to influence prescribing. Four bodies of literature were identified as being important for developing the model: (1) Theoretical prescribing models furnish information concerning factors that affect prescribing and how prescribing decisions are made. (2) Theories of persuasion provide insight into important components of educational communications. (3) Research articles of programs to improve prescribing identify types of programs that have been found to be successful. (4) Theories of human inference describe how judgments are formulated and identify errors in judgment that can play a role in prescribing. This review is presented in two parts. This article reviews prescribing models, theories of persuasion, studies of administrative programs to control prescribing, and sub-optimally designed studies of educational efforts to influence drug prescribing.

Determining physicians' performance. Continuing medical education and other interacting variables

Participation in formal continuing medical education (CME) is required by many organizations and state governments as the foremost means of assuring the quality of medical care. Analysis of the literature reveals that CME in all its forms is effective in improving competence, i.e., the ability to provide good care. However, that competence is not regularly reflected in physicians' habitual performance in the care of patients. A number of factors are known to narrow the gap between competence and performance, including clear specification of standards, individual feedback on actual performance, and a professional environment conductive to the maintenance of high standards. In the presence of such factors, CME can improve physicians' performance when directed to objectively identified deficiencies. However, public assurance of the quality of medical care can only be provided through certification that individual physicians' performance conforms to contemporary valid standards.

Do prescriptions adversely affect doctor-patient interactions?

The purpose of this study was to assess the impact of the prescription on the doctor-patient interaction. Data were collected during ongoing quality assessment studies at a prepaid group practice of about 19,000 enrollees. Adult patients and their providers completed forms on all visits to the Department of Medicine and Urgent Care Center during a two-week period. A 50 percent random sample of patients was interviewed by telephone one week after the index visit. Patients who did not receive prescriptions reported more satisfaction with the communicative aspects of their visits to physicians than patients who did receive prescriptions. We suggest that prescriptions may hinder patient satisfaction with the doctor-patient interaction by substituting for other, more "meaningful" communication between patient and provider.

Are benzodiazepines overused and abused?

1 Drug use has to be viewed in the context of symptoms or illnesses for which they are prescribed. It is concluded that overall psychotropic drugs are used conservatively. 2 The benzodiazepines are safe drugs and in contrast with other centrally acting agents overuse will rarely have severe consequences. 3 Abrupt discontinuation may lead to temporary withdrawal reactions in patients who have been taking benzodiazepines regularly for 4 months or longer. Such reactions may occur more frequently in patients taking high doses.

Effectiveness of continuing medical education: a review of the evidence

Evidence regarding the effectiveness of continuing medical education (CME) is reviewed in terms of three possible end- products : physician competence, physician performance, and patient health status. Results of this review are presented in the context of recent increases in mandatory CME policies and the corresponding cost of such policies to the nation. The number of CME activities is evidently on the increase. Yet, according to conventional wisdom, CME is not effective. To the contrary, about half of the 47 evaluation studies published since 1960 reported demonstrable improvement in at least one of the three end-products following CME. However, methodological shortcomings in many of these studies make it impossible to conclude that the improvements were caused by the CME. The authors discuss the need for more research surrounding the subject of CME and its effectiveness.