Interfacing managed care and long-term care: understanding the issues.

Both marketplace forces and legislative initiatives are forcing the traditional fee-for-service long-term health care sector into the managed care arena. To identify and address the issues surrounding quality and cost-effective pharmaceutical use at the interface between managed care and long-term care, the Philadelphia College of Pharmacy and Science convened a day-long conference between managed care and long-term care medical and pharmacy directors. This paper outlines the discussion and recommendations in respect to these issues.

Retiree health care: a new model for improving health and reducing costs.

Managing the use of prescription drugs in older adults is an area of particular concern because inappropriate medications so frequently trigger additional health care utilization and expenditures in this population. Pharmacists, as the crucial link in the treatment chain between physician and patient, are well positioned to play a key role in this effort. This article describes a new health management approach to coordinating prescription services for older adults.

Managed care organizations: the new research partners.

The current "accountability movement" in managed care demands many of the same components as good research methodology: both issues depend on comprehensive data sources, knowledgeable data manipulation, and credible reporting of the results. As a result, some plans that have earmarked resources and institutional support to good accounting practices are also forming centers of research. The following is an overview of these managed care organizations and their studies, which investigate questions most relevant to their populations and data sources. This article summarizes this expanding area of health services research and identifies the key institutional components of the plans that support this work.

Effect of the prospective-pricing system on drug use in Pennsylvania long-term-care facilities.

Health status, nondrug treatment, and drug use were compared for patients discharged from hospitals to seven long-term-care facilities (LTCFs) in Pennsylvania before and after implementation of the prospective-pricing system (PPS) for hospitalized Medicare patients. Data were collected from medical records of LTCF patients for August 1982 through July 1983 (pre-PPS) and August 1985 through July 1986 (post-PPS). Patients in the post-PPS group (n = 297) had greater numbers of illnesses and more serious illnesses on admission to the LTCFs and were more likely to be readmitted to hospitals than pre-PPS patients (n = 312). Patients in the post-PPS group required more nondrug treatments such as urinary catheters, nutritional supplements, and oxygen and received significantly more drug therapy. The cost of drugs was 50% higher in the PPS group. The post-PPS patients admitted to the LTCFs apparently required more posthospital drug and non-drug therapy than the pre-PPS patients. Any system for prospective pricing in LTCFs should take into account the increases in costs for providing long-term care, including drug therapy, that have occurred since prospective pricing for hospitalized patients began.

Common gastrointestinal diseases in the elderly.

Gastrointestinal diseases, such as gastroesophageal reflux (GER) and peptic ulcers, are prevalent in the elderly. These disorders have been found to develop because of an imbalance between aggressive and defensive physiologic factors, but specific causes remain unknown. If neglected or improperly treated, gastrointestinal disease can cause serious complications, particularly in the elderly. Pharmacologic therapy has proven effective for treating both GER and peptic ulcers.

Patient shifting as a response to Medicare Prospective Payment.

The Medicare Prospective Payment System (PPS) regulations provide hospitals with strong incentives to discharge patients sooner. It seems reasonable to assume that a large number of these discharged patients may require posthospital care in long-term care facilities (LTCFs). Such shifting of patients from hospitals to LTCFs would be evidenced by a sicker population of patients requiring more extensive and intensive treatments in the post-PPS period. The purpose of this study was to determine the extent to which patient shifting occurred after implementation of the PPS regulations. Data were collected from the medical records of 353 patients admitted to 10 LTCFs in Georgia both before and after the PPS was implemented. Comparisons of the two groups indicated no significant differences in LTCF admitting diagnoses, numbers of patients dying or being readmitted to the hospital within 30 days of LTCF admission, prognosis, or rehabilitative potential. The groups differed to a statistically significant extent on three treatment and health status variables: patients in the post-PPS group were more likely to be incontinent of bladder, to have nasogastric tubes, and to be on dietary supplements. These differences may suggest the beginning of a trend to shift heavier care patients into LTCFs. As a whole, however, the results of this study indicated limited shifting of patients from hospitals to LTCFs in Georgia during the first year after implementation of the PPS regulations.

Current concepts in clinical therapeutics: Parkinson's disease.

The etiology, pathophysiology, diagnosis and clinical presentation, and clinical management of Parkinson's disease are reviewed. The cause of Parkinson's disease, a progressive, degenerative neurologic motor disorder, is unknown. Both endogenous and environmental factors appear to play a role. The clinical features of parkinsonism result from a depletion in dopaminergic transmission in the corpus striatum; the dopamine deficiency is caused by a loss of melanin-containing nerve cells within the substantia nigra and locus ceruleus. In the remaining neurons, hyalin-like masses called Lewy bodies increase in number, but the importance of this is unclear. The diagnosis of Parkinson's disease is based on the clinical presentation of the patient, which initially includes sensory complaints of aching pains, paresthesias, numbness, and coldness. As the disease progresses, the four classic symptoms become prominent: tremor, rigidity, bradykinesia, and postural difficulties. Drug therapy is the cornerstone of clinical management of Parkinson's disease, but no treatment has been found that will retard or reverse the disease. Therapy is usually initiated with anticholinergic agents such as biperiden hydrochloride or trihexyphenidyl hydrochloride with or without amantadine. The mainstay of therapy is levodopa, which is used in combination with dopa decarboxylase inhibitors to decrease the peripheral conversion of levodopa to dopamine. Bromocriptine is a dopamine agonist useful in treating Parkinson's disease. Therapy, which must continue for life, eventually becomes less effective or completely ineffective in all patients. Drug therapy has improved greatly the functional ability of patients with Parkinson's disease, but new agents that can extend the length of effective treatment or reverse the disease are needed.

Senile dementia of the Alzheimer type.

The etiology, pathophysiology, neurochemistry, diagnosis, clinical presentation, and management of senile dementia of the Alzheimer type (SDAT) are discussed. The etiology of SDAT is unclear. The pathophysiologic changes in the brain tissue of patients with SDAT are quantitative rather than qualitative in comparison to normal age-matched controls. The number of neuritic plaques and neurofibrillary tangles are positively correlated to the severity of clinical symptoms and cognitive impairment. There is overwhelming evidence that SDAT is associated with a loss of cholinergic function. Reduction of choline acetyltransferase activity, a cholinergic marker, has been significantly correlated to the severity of dementia. The diagnosis of SDAT is one of exclusion and is based upon clinical presentation and neurological, psychological, and laboratory testing. The clinical presentation of SDAT involves the progressive deterioration of intellectual capabilities. Management of SDAT primarily involves supportive care and symptom control. Attempts to treat the disease with cerebral vasodilators, metabolic enhancers, and neurotransmitter manipulation have been largely unsuccessful. Drug therapy aimed at reversing or retarding the progression of the disease is not recommended. Behavioral disturbances represent the main indication for drug use in patients with SDAT. The antipsychotic agents are considered the drugs of choice. SDAT remains an enigma. The successes in the treatment of the disease are few, but as more information is gathered on the neurochemical abnormalities involved, there is hope that early detection can prevent the disease or at least slow its progression.

Practice patterns of Doctor of Pharmacy graduates: educational implications.

The purpose of this study was to evaluate the appropriateness of the predominantly clinical PharmD curriculum in light of actual employment patterns of PharmD graduates. Data were gathered via a survey of PharmD graduates from the seven post-baccalaureate programs active since 1972. Respondents were asked about their employment patterns and characteristics; about their formal education in the areas of management, statistics, and research methods; and to indicate whether they had completed residencies or fellowships. The results indicate that many PharmD graduates are employed in positions requiring considerable nonclinical skills, especially management skills. The results further indicate that few respondents have completed formal education, residencies, or fellowships which would prepare them for management or other nonclinical positions. Consequently, it appears that PharmD programs should require considerably more management training and education in order to adequately prepare their graduates for the positions open to them.

Pharmacokinetics of theophylline in young and elderly subjects.

Theophylline kinetics were evaluated in 6 elderly (age 65-75 years) and 5 young (age 22-28 years), nonsmoking males following the oral administration of 200 mg of Elixophylline. Theophylline serum concentration in the postabsorptive phase declined in a monoexponential manner. Total body clearance, elimination half-life, volume of distribution and protein binding were determined. There were no statistically significant differences in these kinetic parameters between the elderly and young subjects. Therefore, advancing age should not be used as a sole factor in the adjustment of theophylline dosage.

Chloramphenicol hemodialysis clearance.

The purpose of this study was to evaluate the dialysis clearance and plasma protein binding of chloramphenicol in a chronic renal failure patient and an acute renal/hepatic failure patient undergoing hemodialysis. Predialysis, dialysis and postdialysis plasma samples were collected and analyzed. Plasma chloramphenicol levels declined slowly during hemodialysis with measured dialysis clearance rates of 21.2 ml/min (patient C.W.) and 24.2 ml/min (patient S.T.). The protein binding of chloramphenicol, determined before and 30 min after hemodialysis, was 40 and 25% (patient C.W.) and 44 and 35% (patient S.T.), respectively. The extent to which hemodialysis removes chloramphenicol from the plasma does not appear significant enough to warrant routine dosage adjustment. The clinical significance of protein binding alterations is discussed.