The effect of comorbidity on use of thrombolysis or aspirin in patients with acute myocardial infarction eligible for treatment.

Objective: Growing evidence indicates that life-sustaining therapies for the treatment of acute myocardial infarction (AMI) are underused among patients eligible for therapy, including the elderly and women. We examined the effect of a patient's comorbidity burden on use of these highly effective therapies in eligible populations of individuals with AMI.

Design: Retrospective cohort design.

Influence of location and staff knowledge on quality of retail pharmacy prescribing for childhood diarrhea in Kenya.

Background: Retail pharmacies are important sources of advice on pharmaceuticals in developing countries, where many purchasing decisions are unmediated by medical professionals. For childhood diarrhea, choice of drug sales in pharmacies has been found to be consistently poor, whether with or without prescription, as evidenced by a low use of effective oral rehydration salts (ORS) and high use of marginally effective or ineffective products such as antimotility agents, adsorbents, and antimicrobials. Little information is available about factors influencing prescribing by pharmacy personnel in these settings.

The impact of face-to-face educational outreach on diarrhoea treatment in pharmacies.

Private pharmacies are an important source of health care in developing countries. A number of studies have documented deficiencies in treatment, but little has been done to improve practices. We conducted two controlled trials to determine the efficacy of face-to-face educational outreach in improving communication and product sales for cases of diarrhoea in children in 194 private pharmacies in two developing countries.

Adherence to national guidelines for drug treatment of suspected acute myocardial infarction: evidence for undertreatment in women and the elderly.

Background: Evidence-based guidelines for the treatment of patients with acute myocardial infarction (AMI) have been published and disseminated by the American College of Cardiology and the American Heart Association. Few studies have examined the rates of adherence to these guidelines in eligible populations and the influence of age and gender on highly effective AMI treatments in community hospital settings.

Methods: Medical records of 2409 individuals admitted to 37 Minnesota hospitals between October 1992 and July 1993 for AMI, suspected AMI, or rule-out AMI, and meeting electrocardiographic, laboratory, and clinical criteria suggestive of AMI were reviewed to determine the proportion of eligible patients who received thrombolytic, beta-blocker, aspirin, and lidocaine hydrochloride therapy.

Retail pharmacies in developing countries: a behavior and intervention framework.

Retail pharmacies in developing countries are one of the most important sources of advice on pharmaceuticals. Among the reasons the clients give are ease of access; availability of medicines; quality of service (no waiting and convenient hours of operation); and cheaper products, availability of credit, or the option to buy drugs in small amounts. However, the appropriateness of prescribing by retail pharmacy staff has been found to be far from acceptable.

The impact of clinical trials on the use of medications for acute myocardial infarction. Results of a community-based study.

Background: The impact of clinical trials on medical practice remains controversial, in part because of weak study designs and nonrepresentative study samples.

Objective: To assess changes in trends in medication use in the setting of acute myocardial infarction (AMI) before and after publication of two large clinical trials: the Second International Study of Infarct Survival (ISIS-2) trial that supported the use of aspirin after AMI and the Multi-center Diltiazem Postinfarction Trial that reported no overall benefit from the use of calcium antagonists after AMI.

Methods: Study patients consisted of 2114 patients hospitalized with AMI in 16 hospitals in metropolitan Worcester, Mass, during 1986, 1988, and 1990.

Do open formularies increase access to clinically useful drugs?

Before 1990 many state Medicaid programs maintained "restrictive" formularies, which denied reimbursement for unlisted prescription drugs. This type of formulary has been criticized for denying important medications to poor, medically needy persons. As part of the Omnibus Budget Reconciliation Act of 1990, restrictive formularies in Medicaid programs were disallowed.

Hemophilia home treatment. Economic analysis and implications for health policy.

This analysis describes the development of technology for home self-infusion of factor VII in the treatment of hemophilia and its clinical, economic, and social consequences, and uses the case study of such home care treatment to illustrate the potentials and pitfalls of formal economic analyses of programs to treat chronically ill children. A comprehensive review of all original data on hemophilia programs, their related costs, and outcomes, conducted from 1966 through 1993, examined the economic outcomes for two hypothetical cohorts, one aged 0-4 years and the other aged 30-34 years. Including the measurement of treatment effects on the productivity of parental caregivers substantially increases the benefit-cost relationship of an intervention directed at chronically ill children.

Pharmacists as agents of change for rational drug therapy.

We analyze what is known and unknown about the contribution of the pharmacist as patient educator, physician consultant, and agent to affect patient outcomes in ambulatory settings. The need for pharmacist services is discussed, as are the theoretical underpinnings and quality of the scientific evidence to support their efficacy. The analysis is conducted in the context of a shift in pharmacists' roles from product to patient orientation as well as recent U.

Effects of a limiting Medicaid drug-reimbursement benefits on the use of psychotropic agents and acute mental health services by patients with schizophrenia.

Background: We examined the effects of a three-prescription monthly payment limit (cap) on the use of psychotropic drugs and acute mental health care by noninstitutionalized patients with schizophrenia. We hypothesized that reducing access to such drugs would increase the use of emergency mental health services and the rate of partial hospitalizations (full-day or half-day treatment programs) and psychiatric-hospital admissions.

Methods: We linked Medicaid claims data for a period of 42 months with clinical records from two community mental health centers (CMHCs) and the single state psychiatric hospital in New Hampshire, where Medicaid imposed a three-prescription limit on reimbursement for drugs during 11 months (months 15 through 25) of the study.

Deliberations on the dissemination of PORT products: translating research findings into improved patient outcomes.

This report outlines the activities undertaken by the Inter-PORT Dissemination work group during its first 2 years of operation. The work group's initial purpose was to assist the individual PORTs in developing their plans for both disseminating research findings and evaluating the effectiveness of these strategies. However, it became quickly apparent that in a discipline little more than a decade old, a commonly understood vocabulary had yet to be adopted.

Examining product risk in context. Market withdrawal of zomepirac as a case study.

Objective: To examine changes in the prescribing of analgesics after the market entry and subsequent withdrawal of zomepirac sodium, a nonsteroidal anti-inflammatory drug (NSAID), following repeated reports of zomepirac-related deaths.

Design: To evaluate this natural quasi experiment, we conducted time-series analyses to compare prescribing in two cohorts of primary care physicians from July 1980 through September 1983.

Setting: Study physicians provided outpatient pharmaceutical care to patients enrolled in the New Jersey Medicaid program.

Influence of knowledge and attitudes on the quality of physicians' transfusion practice.

Studies evaluating relationships between physician background characteristics (e.g. years of practice and medical training) and quality of care have found few consistent associations.

A controlled trial of educational outreach to improve blood transfusion practice.

Objective: To determine whether brief, face-to-face educational outreach visits can improve the appropriateness of blood product utilization.

Design: Randomized, controlled multicenter trial with 6-month follow-up.

Setting: Surgical and medical services of two pairs of matched community and teaching hospitals in Massachusetts.

A critical analysis of studies of state drug reimbursement policies: research in need of discipline.

Concerns over pharmaceutical costs and appropriateness of medication use have led state Medicaid programs to restrict drug reimbursement. This article critically reviews 20 years of research on cost sharing, drug reimbursement limits, and administrative limitations on access to particular drugs via formularies, category exclusions, or prior authorization requirements; evaluates their methodological rigor; summarizes the state of current knowledge; and proposes future research directions. Drug reimbursement caps and modest cost sharing can reduce the use of both essential and less important drugs in Medicaid populations; severe reimbursement caps may precipitate serious unintended effects.

A randomized trial of a program to reduce the use of psychoactive drugs in nursing homes.

Background: Although psychoactive medications have substantial side effects in the elderly, these drugs are used frequently in nursing homes. Few interventions have succeeded in changing this situation, and little is known about the clinical effects of such interventions.

Methods: We studied six matched pairs of nursing homes; at one randomly selected nursing home in each pair, physicians, nurses, and aides participated in an educational program in geriatric psychopharmacology.

Reducing the use of H2-receptor antagonists in the long-term-care setting.

Objectives: To examine the patterns of H2 blocker use in the long-term-care setting and to assess the effect of educational interventions designed to improve H2 blocker utilization patterns.

Design: Time-series quasi-experimental study and retrospective chart review.

Setting: A large academically-oriented long-term-care facility.

Computer-assisted drug data collection.

Computerized systems for recording information about medication prescribing and use are important for studies in health services and pharmacoepidemiology. Such systems, if properly designed, can facilitate analysis as well as data collection. Although drug information systems exist for pharmacy service delivery applications, there are currently no descriptions of systems developed primarily for research applications in this area.

Effects of professional and media warnings about the association between aspirin use in children and Reye's syndrome.

The media played a central role in changing the use of aspirin among children with viral illness following reports of its association with a rare but deadly disease, Reye's syndrome (RS). It did so by alerting health professionals and parents about ways to prevent RS in children. Indeed, by the time aspirin product labeling was required by the FDA in 1986, most of the decline in RS incidence had already occurred.

Effects of Medicaid drug-payment limits on admission to hospitals and nursing homes.

Background: Many state Medicaid programs limit the number of reimbursable medications that a patient can receive. We hypothesized that such limitations may lead to exacerbations of illness or to admissions to institutions where there are no caps on drug reimbursements.

Methods: We analyzed 36 months of Medicaid claims data from New Hampshire, which had a three-drug limit per patient for 11 of those months, and from New Jersey, which did not.