Antidepressant prescribing patterns: a comparison of blacks and whites in a medicaid population.

OBJECTIVE: This paper reports results stemming from a retrospective inquiry designed to determine the prescribing pattern of tricyclic antidepressants (TCAs) relative to selective serotonin reuptake inhibitors (SSRIs), and the subsequent effect on regimen adherence among African American (Black) and White beneficiaries enrolled in the state of South Carolina Medicaid programme. PATIENTS AND METHODS: Adjudicated patient-level paid-claims data for the time-frame 1 January 1990 to 31 December 1994 were abstracted resulting in a statewide cohort of 8596 ambulatory beneficiaries, 18 to 64 years of age, without receipt of antidepressant pharmacotherapy in the 1-year time-frame prior to initiating a regimen of either a TCA or SSRI, and remaining Medicaid-eligible for 1 year thereafter. RESULTS: Black race [odds ratio (OR) = 1.56, 95% confidence interval (CI) = 1.43 to 1.70], age 40 to 64 years (OR = 1.15, 95% CI = 1.06 to 1.26), and male gender (OR = 1.27, 95% CI = 1.14 to 1.41) were significant predictors of initiating antidepressant pharmacotherapy with a TCA. Relative to Whites, Blacks were found to be less likely to have obtained at least a 3-month (>/=90 days) supply of a TCA (22.1 vs 31.7%) or an SSRI (30.7 vs 36.1%), or to have obtained a 6-month (>/=180 days) supply of a TCA (6.4 vs 10.9%) or an SSRI (8.1 vs 13.2%). CONCLUSION: Further prospective research is required to discern the reasons for observed differences in prescribing and adherence patterns for antidepressant pharmacotherapy by age, gender and race, and to foster the development of educational programming designed to ensure clinically rational and equitable access to pharmacotherapeutic innovation.

Economic impact of cost-containment strategies in third party programmes in the US. Part II.

This is the second article in a 2-part series that examines the economic impact of several different strategies used to control costs in third party programmes. This article investigates 5 different methods: (a) formularies; (b) capitation; (c) drug utilisation review; (d) prior approval; and (e) drug product selection. The published literature indicates that use of formularies decreases drug expenditures, but these savings may be offset by expenditures in other areas of healthcare programmes. Capitation, though less well studied than other strategies, may show some effectiveness in reducing costs by increasing generic dispensing and promoting switching from prescription drug to over-the-counter. Drug utilisation review, as a systematic programme of claims data review, has been shown to yield positive economic return in a variety of areas, including both impersonal and face-to-face educational interventions with healthcare practitioners. Prior approval and drug product selection both result in savings when examined in isolation from other aspects of healthcare. Cost-shifting, administrative costs and costs incurred because of possible decreased access to care have yet to be fully accounted for.

An evaluation of a program to regulate rural hospital costs: the Finger Lakes Hospital Experimental Payment program.

In 1981 eight small- and medium-sized hospitals in a rural area of New York State began voluntary participation in the Finger Lakes Hospital Experimental Payment (FLHEP) program. An annual maximum reimbursement formula was set for each hospital, which offered financial incentives to contain the growth in expenditures without penalty in subsequent years. In this analysis of the first three years of the program, we found that the growth in revenues and expenses in study group hospitals was reduced and chronic deficits were eliminated. The FLHEP model may have wider potential for ensuring solvency while controlling expenditures of hospitals in other rural areas of the United States.

The effect of a Medicaid drug copayment program on the utilization and cost of prescription services.

The effect of a copayment for pharmaceutical services in a Medicaid program is presented. Data were collected from Medicaid claim files in South Carolina (experimental program) and Tennessee (control program) for a 4-year period, 1976-1979. Utilization rates and expenditures for 1 year prior to copayment and 3 years after copayment were computed from a stratified sample of 18 counties. Both the level of prescriptions per eligible recipient and the slope of the utilization function after copayment were found to have declined with the implementation of copayment in South Carolina. The level of the expenditure series after copayment also declined, but the series retained a positive trend. Subsequent analysis of prescription quantity concluded that the increasing expenditure function was attributed to the inflation in cost of ingredients rather than an increase in average prescription size. The study concluded that a small (50) copayment for prescription service is a successful mechanism to control the cost and assist in financing a Medicaid prescription drug program.

Access to generic drugs in the 1950s: the politics of a social problem.

From the published literature of the 1950s, the social history of anti-substitution law is analyzed in terms of sociological theory on the construction of social problems. The analysis reveals how the substitution of generic drugs for prescribed brands came to be recognized as a social problem in need of remedial legislation. The most influential party in the process was the brand-drug industry which centered the debate on matters of public health and professionalism instead of industrial profitability. The industry was able to form a coalition of interests and establish the saliency and legitimacy of the problem, even though there was no objective evidence to establish brand substitution as a hazard to health. The case fits well into the theory of social problem construction. Other issues in health care, particularly drug issues can be studied from this same perspective.

Impact of drug substitution legislation--implications for continuing education for Michigan pharmacists.

In June 1974, Michigan Public Law 155 was enacted. This law permits a pharmacist to exercise drug product selection under specified conditions. The intent of the legislation is to achieve savings in prescription drug costs by encouraging pharmacists to dispense less costly, generically equivalent products. For this legislation to be effective, there have to be many substitutable products for a sufficient number of drugs; there has to be minimal interference with pharmacists' judgment; and pharmacists must be aware of the products available. As part of a survey, we attempted to measure physicians' and pharmacists' knowledge of generically equivalent products. Pharmacists demonstrated a higher level of knowledge of drug products. Continuing education must respond to the needs of more complicated societal demands.

Evaluation of economic effects of drug product selection legislation.

Drug product selection legislation is intended to achieve savings in the cost of prescription drugs without adversely affecting the quality of care by allowing pharmacists the opportunity to dispense less costly generically equivalent drug products in place of the product which had been prescribed by the physician. Various conditions under which the pharmacists are authorized by state laws to exercise theoption to substitute are discussed. The study then identifies and examines the conditions under which savings may and do occur, using the legislation in Michigan as the model. Over 60,000 acutal prescriptions were examined for the three-year period, April 1, 1974 through March 31, 1977--which covers the period of the year immediately before the legislation became effective and the two subsequent years-to determine: 1) the extent to which substitution is possible; 2) potential savings from generic substitution; and 3) very substantial potential cost savings from drug product selection, the actual savings represent only an extremely small proportion of the potential. This principally is due to the fact of the low rate of substitution among eligible prescriptions. Thus, if the gap between actual and potential savings is to be reduced, more attention must be given to affecting the pattern of drug selection among pharmacists.

Measuring pharmacist time use: a note on the use of fixed-interval work sampling.

Pharmacist time use was studied to examine whether fixed-interval work sampling would provide results comparable to those obtained when random-interval observations were used. The study was conducted over a three-month period using pharmacists in a single community pharmacy as subjects; similar study methods have been used in hospital settings. Four separate measures of pharmacist time use were designated: tasks, duties, competencies and productivity. In every case the fixed-interval method gave an estimate that was not significantly different from the random-interval procedure (alpha greater than 0.05, difference of proportions test). The findings suggest that pharmacist work patterns are not sufficiently cyclical to introduce a bias in work sampling by fixed intervals. Fixed-interval work sampling yields results comparable to those using the standard work sampling methods that rely upon random time periods between observations.

Blood flow to the uterine tube (oviduct) of the early pregnant and pseudopregnant rabbit.

Blood flow to the uterus and uterine tube was measured in 46 rabbits in estrus and early pregnancy or pseudopregnancy. Uterine blood flow in estrus averaged 0.910 +/- 0.253 (SD) ml/g/minute and remained unchanged through postcoital day (PCD) 15. Blood flow to the uterine tube in estrus was 0.810 +/- 0.287 ml/g/minute. A peak blood flow of 1.323 +/- 0.424 ml/g/minute, was measured in the uterine tube on PCD 4, followed by a decrease of blood flow to estrous levels on PCD 8 to 15. The gross blood vasculature of the uterus uterine tube, and ovary was studied by intravascular silicone rubber injection in 17 rabbits. The architecture of the blood vascular system remained unchanged from estrus through early pregnancy or pseudopregnancy. The differences were vascularization of the corpus luteum, vascular accommodation of uterine distension, and enlargement of the lateral arcuate vein which spans the uterotubal junction.