Disease State Management.

OBJECTIVE: To explore how healthcare management has evolved from managing separate components to disease management. DATA SOURCES: Recent published atricles and the authors' experiences. STUDY SELECTION: Not applicable. DATA EXTRACTION: Not applicable. DATA SYNTHESIS: Disease state management integrates services from all areas of healthcare. To evaluate whether a disease is being treated effectively, clinical, physical, and quality of life, indicators need to be measured. Protocols and intervention strategies need to be developed at minimal cost without compromising patient care. Patient and physician satisfaction need to be evaluated to measure the success of the disease management process. CONCLUSION: The old paradigm of component management of medical care is losing ground and being replaced by systems focused on patient outcomes as the best way to deal with the issues of access, quality, and cost. KEY WORDS: Disease state management, Outcomes, Costs.

Effects of the 2009 USPSTF Depression Screening Recommendation on Diagnosing and Treating Mental Health Conditions in Older Adults: A Difference-in-Differences Analysis.

BACKGROUND: Depression is a common mental condition in U.S. older adults. To improve rates of underdiagnosis and undertreatment for depression and other mental health conditions in primary care settings, the U.S. Preventive Services Task Force (USPSTF) updates and disseminates its depression screening guideline regularly. OBJECTIVE: To examine the effects of the 2009 USPSTF depression screening recommendation on the 3 following outcomes: diagnoses of mental health conditions, antidepressant prescriptions (overall and potentially inappropriate), and provision of nonpharmacological psychiatric services in office-based outpatient primary care visits made by adults aged 65 or older. METHODS: Data from the 2006-2012 National Ambulatory Medical Care Survey (NAMCS), a nationally representative sample of office-based outpatient primary care visits among older adults (n = 15,596 unweighted), were used. NAMCS represents physician practicing patterns of ambulatory medical care services utilization at the national level. Using a series of multivariate difference-in-differences analyses, we estimated effects of the USPSTF depression screening recommendation on the previously mentioned outcomes by comparing pre- (2006-2009) and post- (2010-2012) periods to describe primary care physician practice patterns. RESULTS: Differences in any mental health diagnosis by the depression screening status were -34.7% in the pre-2009 period and -20.2% in the post-2009 period, resulting in a differential effect of -14.4% (95% CI = -28.2, -0.6; P = 0.040). No differential effect was found in other outcomes. CONCLUSIONS: While there are mixed findings about efficacy and effectiveness of depression screening in the existing literature, more population-based observational research is needed to strengthen and support current USPSTF depression screening recommendation statements in the United States. DISCLOSURES: Funding for this study was provided by the National Institute on Aging of the National Institutes of Health (#T32AG019134). The authors declare that they do not have any conflicts of interest. Publicly available data were obtained from the National Center for Health Statistics (NCHS) of the Centers for Disease Control and Prevention (CDC). Analyses, interpretation, and conclusions are solely those of the authors and do not necessarily reflect the views of the Division of Health Interview Statistics or NCHS of the CDC.

A 15 Year Ecological Comparison for the Market Dynamics of Minnesota Community Pharmacies from 2002 to 2017.

Background: Understanding the factors that influence the market entry, exit, and stability of community pharmacies (i.e., market dynamics) is important for stakeholders ranging from patients to health policymakers and small business owners to large corporate institutions. Objective: The study's first objective was to describe the market dynamics of community pharmacies for Minnesota counties in 2002, 2007, 2012, and 2017 by associating county (a) population density and (b) metropolitan designation with the change in the number of 'All community pharmacies,' 'Chain community pharmacies', and 'Independent community pharmacies'. The study's second objective was to describe the number and proportion of community pharmacies for Minnesota counties in 2002, 2007, 2012, and 2017 by (1) 'Business Organization Structure' and (2) 'Pharmacy Type.' Methods: County-level data were obtained from the Minnesota Board of Pharmacy, US Census Bureau, and Minnesota State Demographic Center for 2002, 2007, 2012, and 2017. Findings were summarized and the associations between study variables described using descriptive statistics. Results: The ratio of 'Independent community pharmacies' to 'Chain community pharmacies' was about 1:1 (466:530) in 2002, 1:2 (352:718) in 2007, 1:2 (387:707) in 2012, and 1:3 (256:807) in 2017. There was not a consistent relationship that carried through the 15 year analysis between county population density and metropolitan designation and the market dynamic patterns of community pharmacies. The types of pharmacy in Minnesota changed significantly over the study with increases in state, regional, and national chains and declines in single entity and small chain independents. There were also notable declines in mass merchandiser community pharmacies and increases in clinic and medical center community pharmacies. Discussion: The findings suggest that different or additional factors beyond traditional market dynamic predictors of population density and metropolitan designation were at play in each five year interval of this study. We propose that the traditional dichotomy of independent and chain community pharmacy groupings no longer provide an optimal characterization for the market dynamics of pharmacies today. Instead, community pharmacies may be better organized by their capacity to operate as healthcare access points that provide and are reimbursed for patient care and public health services like medication therapy management, immunizations, and more. Conclusions: The findings showed that community pharmacy distribution in Minnesota's 87 counties has shifted between 2002 and 2017 from traditional retail models to emerging healthcare models based on population health needs. This signals the need for not only a new approach for tracking community pharmacy market dynamics but also adjustments by community pharmacies to remain relevant in a new environment of patient care services.

Effects of depression screening on diagnosing and treating mood disorders among older adults in office-based primary care outpatient settings: An instrumental variable analysis.

Existing literature shows mixed findings regarding the efficacy and effectiveness of depression screening, and relatively little is known about the effectiveness of depression screening among older adults in primary care visits in the U.S. This study examines the effects of depression screening on the three following outcomes: mood disorder diagnoses, overall antidepressant prescriptions, and potentially inappropriate antidepressant prescriptions among older adults ages 65 or older in office-based outpatient primary care settings. We used data from 2010-2012 National Ambulatory Medical Care Survey (NAMCS), a nationally representative sample of office-based primary care outpatient visits among older adults (n=9,313 unweighted). We employed an instrumental variable approach to control for selection bias in our repeated cross-sectional population-based study. Injury prevention and stress management were selected as instrumental variables, as they were considered completely exogenous to outcomes of interests using conceptual and statistical criteria. We conducted multivariate bivariate probit (biprobit) regression analyses to investigate the effect of depression screening on each outcome, when controlled for other covariates. We found that depression screening was negatively associated with potentially inappropriate antidepressant prescriptions (ß=-2.17; 95% CI -2.80 to -1.53; p<0.001). However, no significant effect of depression screening on diagnosis of mood disorders and overall antidepressant prescriptions was found. Overall, depression screening had a negative effect on potentially inappropriate antidepressant prescriptions. Primary care physicians and other healthcare providers should actively utilize depression screening to minimize potentially inappropriate antidepressant prescriptions in older adult patients.

Pharmacy Students' Attitudes Toward Debt.

OBJECTIVE: To examine pharmacy students' attitudes toward debt. METHODS: Two hundred thirteen pharmacy students at the University of Minnesota were surveyed using items designed to assess attitudes toward debt. Factor analysis was performed to identify common themes. Subgroup analysis was performed to examine whether students' debt-tolerant attitudes varied according to their demographic characteristics, past loan experience, monthly income, and workload. RESULTS: Principal component extraction with varimax rotation identified 3 factor themes accounting for 49.0% of the total variance: tolerant attitudes toward debt (23.5%); contemplation and knowledge about loans (14.3%); and fear of debt (11.2%). Tolerant attitudes toward debt were higher if students were white or if they had had past loan experience. CONCLUSION: These 3 themes in students' attitudes toward debt were consistent with those identified in previous research. Pharmacy schools should consider providing a structured financial education to improve student management of debt.

Development of an adverse-event coping scale (AECS) using item response theory.

BACKGROUND: Adverse drug events (ADEs) cause significant morbidity and mortality to patients. A brief questionnaire asking patients how they coped with such problems could be a useful tool for providing timely interventions. OBJECTIVE: The aim of this study was to develop an adverse-event coping scale (AECS) to measure patients' coping responses to their ADE. METHODS: Data were collected from subjects recruited from community pharmacies. Psychometric analyses based on item response theory (IRT) were performed to calibrate items and assess reliability. Convergent validity was evaluated by testing a priori formulated hypotheses about expected correlations between the coping scores and other related scales. RESULTS: A total of 140 patients participated in this study by answering the developed items. Confirmatory factor analysis supported a one-dimensional item bank with 11 items. The developed scale was reliable with the reliability coefficient of 0.82. Coping scores were positively correlated with seriousness of the ADE and health literacy, but not coping self-efficacy. Overall, results suggest that the score reflects problem magnitude and coping effort rather than coping efficacy. CONCLUSION: A high score on the AECS indicates an ADE serious enough to prompt a patient to invest substantial efforts to cope with it. The final AECS item bank and its short-form can help clinicians better understand their patients' ADE-coping efforts.

Integrating a pharmacist into a home healthcare agency care model: impact on hospitalizations and emergency visits.

Medication regimens can be complicated during the transition from hospital to home for a variety of reasons. The primary purpose of this retrospective study was to measure the impact of integrating a pharmacist into a model of care at a Medicare-certified home healthcare agency for clients recently discharged from the hospital. The secondary purpose was to describe the medication-related problems among clients receiving services from the model of care involving a pharmacist. Integrating a pharmacist within the model of care demonstrated a positive clinical impact on clients.

Market dynamics of community pharmacies in Minnesota, U.S. from 1992 through 2012.

BACKGROUND: An understanding of community pharmacy market dynamics is important for monitoring access points for pharmacist services. OBJECTIVES: The purpose of this study was to describe (1) changes in pharmacy mix (independent versus chain) between 1992 and 2002 and between 2002 and 2012 for 87 counties in Minnesota (state in U.S.) and (2) the number (and proportion) of community pharmacies in Minnesota for the years 1992, 2002, and 2012 using a new categorization method developed specifically for this study. METHODS: Data included licensure records for 1992, 2002, and 2012 from the State of Minnesota Board of Pharmacy and county level demographics for 1990, 2000 and 2010 from the US Census Bureau. Descriptive statistics were used to summarize findings over time and to describe associations between study variables. RESULTS: The ratio of independent pharmacies to chain pharmacies changed from approximately 2:1 in 1992 to 1:2 in 2012. The primary market factors associated with changes in the number of community pharmacies per county were (1) the metropolitan designation of the county and (2) whether the population density (persons/square mile) was increasing or decreasing. The face of community pharmacy in Minnesota changed between 1992 and 2012. By 2012, pharmacies were located in traditional retail pharmacies, mass merchandiser outlets, supermarkets, and clinics/medical centers. Furthermore, specialty pharmacies grew in proportion to meet patient needs. CONCLUSIONS: Between 1992 and 2012, the market dynamics of community pharmacies in Minnesota was characterized by vigorous market entry and exit. In light of recent health reform that is exhibiting characteristics such as continuity-of-care models, performance-based payment, technology advances, and the care of patients becoming more "ambulatory" (versus in-patient), we suggest that the market dynamics of community pharmacies will continue to exhibit vigorous market entry and exit in this new environment. It is proposed that the community pharmacy categories developed for this study will be useful for monitoring market dynamics in the future.

Effects of anthropomorphic images and narration styles in promotional messages for generic prescription drugs.

BACKGROUND: Anthropomorphism is attribution of human characteristics to nonhuman objects or events. Marketers have used anthropomorphized characters to promote products and services. To promote use of generic drugs to save on prescription drug costs, health systems are in the process of developing informational materials to influence consumer's perceptions about generic prescription drugs. OBJECTIVES: To evaluate the effects of anthropomorphic images (control vs caring vs authoritative) and information narration styles (first person vs third person) on (1) social presence, (2) attitude toward the overall promotional message, (3) perceived informativeness of the message content, (4) attitude toward specific message, (5) intent to seek information, and (6) intention to switch to a generic prescription drug. METHODS: A 3×2 between-subject factorial design was used. Student participants were administered a mock promotional message regarding generic prescription drugs. Following the promotional message, they were asked to respond to items developed to measure the effects of the promotional message. Manipulation checks were conducted to test the desired effects of the independent variables. Pilot testing, exploratory factor analysis, and reliability testing of the item measures were conducted before their use in the study. Analysis of variance was used to analyze the data and test the proposed effects of the independent variables. RESULTS: Anthropomorphic images showed a positive effect on social presence and attitude toward the specific message. Narration styles had a positive effect on attitude toward the overall promotional message. Neither anthropomorphic images nor narration styles had a significant effect on perceived informativeness, intent to seek information, and intention to switch to a generic prescription drug. CONCLUSIONS: This research reveals that anthropomorphism of medications and narration styles could play a significant role in promotional messages for generic prescription drugs. These findings provide a new direction in developing educational materials for information about generic prescription drugs.

PDP or MA-PD? Medicare part D enrollment decisions in CMS Region 25.

BACKGROUND: The Medicare Prescription Drug Improvement and Modernization Act of 2003 provides outpatient prescription drug coverage for Medicare beneficiaries through private insurers. This coverage is available through 2 primary venues: stand-alone prescription drug plans (PDPs) and integrated managed care (or Medicare Advantage) plans that also provide prescription drug coverage (MA-PDs). OBJECTIVES: The first objective was to describe factors associated with Medicare beneficiaries choosing to enroll in any Medicare part D PDP. The second objective was to describe factors associated with the choice of an MA-PD, given enrollment in the part D program. METHODS: The study used a cross-sectional, survey design. Data were collected from a stratified random sample of 5000 community-dwelling adults, aged 65 years and older in the Center for Medicaid and Medicare Services Region 25. Data were collected by means of a mailed questionnaire. Data analyses included univariate and bivariate descriptive statistics and multivariate probit modeling. RESULTS: The overall adjusted response rate was 50.2% (2309 of 4603). Data from 1490 respondents (32.4% of those attempted) were analyzed in this study. Nearly 75% of sample members elected to enroll in one of the Medicare part D coverage options in 2007, with more than 3 times as many choosing a PDP compared with a MA-PD option (57.2% vs 17.8%). A variety of variables including rurality, plan price, perceived future need for medications, and preferences emerged as important predictors of choosing to enroll in any Medicare part D drug plan, whereas rurality, state of residence, and number of diagnosed medical conditions were associated with the decision to enroll in a MA-PD. CONCLUSIONS: Models of health insurance demand and plan choice applied in this context appear to be modestly effective. Rurality and state of residence were particularly important contributors to both of these decisions, as were a variety of individual characteristics.

Retrospective assessment of Medicaid step-therapy prior authorization policy for atypical antipsychotic medications.

BACKGROUND: Antipsychotic medications account for more prescription expenditures in Medicaid than any other therapeutic category. This has made them an attractive target for states hoping to curtail rising expenditures. OBJECTIVE: The objective of this study was to document the effects of a step-therapy prior authorization (PA) policy for atypical antipsychotic medications on: (1) Medicaid prescription expenditures among all Medicaid beneficiaries and (2) prescription and health service expenditures among patients with schizophrenia. METHODS: Prescription, inpatient, outpatient, and long-term care State Medicaid Research Files from Georgia and Mississippi from January 1, 1996, to December 31, 1997, were used to model an interrupted time-series analysis. We compared a step-therapy PA policy implemented in Georgia to a nonequivalent/no-treatment control group (Mississippi) over 10-month prepolicy, 11-month policy, and 3-month postpolicy periods. Segmented regression was used to estimate antipsychotic prescription expenditures among all eligible Medicaid beneficiaries. We used generalized estimating equations to model prescription and other health service expenditures with difference-indifference regressions among a cohort of patients with schizophrenia. RESULTS: Compared with Mississippi, Georgia saved approximately USD 7 million in atypical antipsychotic expenditures over the 11-month policy period. Among patients with schizophrenia, the PA policy was associated with a USD 19.62 per member per month (PMPM) decrease in atypical antipsychotic expenditures and a USD 2.20 PMPM increase in typical antipsychotic expenditures (both, P < 0.001). Among the same patients with schizophrenia however, the reduction in atypical antipsychotic expenditures was accompanied by a USD 31.59 PMPM increase in expenditures for outpatient services (P < 0.001). CONCLUSION: Although PA of atypical antipsychotics was associated with significant prescription savings to the Georgia Medicaid program, among a vulnerable cohort of patients with schizophrenia, an increase in outpatient expenditures was associated with overall savings.

Third-year pharmacy students' work experience and attitudes and perceptions of the pharmacy profession.

OBJECTIVES: To describe PharmD students' work experiences and activities; examine their attitudes towards their work; examine perceptions of preceptor pharmacists they worked with; and determine important issues associated with career preference. METHODS: A written survey was administered to third-year doctor of pharmacy (PharmD) students at 8 colleges and schools of pharmacy in the Midwest. RESULTS: Five hundred thirty-three students (response rate = 70.4%) completed the survey instrument. Nearly 100% of PharmD students reported working in a pharmacy by the time their advanced pharmacy practice experiences (APPEs) began. Seventy-eight percent reported working in a community pharmacy, and 67% had worked in a chain community pharmacy. For all practice settings, students reported spending 69% of their time on activities such as compounding, dispensing, and distribution of drug products. CONCLUSIONS: Most students are working in community pharmacy (mainly chain) positions where their primary function is traditional drug product dispensing and distribution. Having a controllable work schedule was the variable most strongly associated with career choice for all students.

Citizen's preferences regarding principles to guide health-care allocation decisions in Thailand.

OBJECTIVES: The objective of this study was to investigate the extent to which five principles of rationing (lottery, rule of rescue, health maximization, fair innings, and choicism) were preferred by a sample of Thai citizens for selecting patients to receive high-cost therapies. METHODS: A self-administered survey was used for collecting data from a sample of 1000 individuals living in Thailand. Descriptive statistics, factor analysis, and multinomial logistic regression analysis were used for describing and validating the data. Out of the 1000 sample members, 780 (78%) provided usable responses. RESULTS: The results showed that within specific situations under budget constraints, Thai people used each of the criteria we studied to ration health care including: 1) lottery principle; 2) rule of rescue; 3) health maximization; 4) fair innings; and 5) choicism. CONCLUSIONS: The extent to which the criteria were applied depended on the specific situation placed before the decision-maker. "Choicism" (equalizing opportunity for health) was the most preferred method for rationing when compared to each of the other four principles.

Professional implications of the expansion of pharmacy-based medical clinics.

OBJECTIVE: To describe challenges and opportunities to the profession of pharmacy associated with the emergence of pharmacy-based medical clinics. SUMMARY: Pharmacy-based medical clinics have emerged as a convenient, low-cost treatment option for many patients. These clinics, which are staffed by physicians' assistants or nurse practitioners, often are located directly within community pharmacies and offer rapid diagnosis and treatment for a limited number of health problems. With plans for significant expansion of these clinics, the profession of pharmacy faces a number of challenges. Allocating space in community pharmacies for medical clinics could place pharmacists at a disadvantage to other providers as they pursue ancillary health care activities. However, these clinics also represent an opportunity for pharmacists to position themselves as legitimized health care providers who are reimbursed for the consultative services they perform. Because most conditions diagnosed at pharmacy-based medical clinics have well-established treatment protocols, pharmacists would be well positioned to provide these services under collaborative practice agreements. This could ultimately provide the resources and payment structure necessary for pharmacists to provide other types of patient care services, including medication therapy management (MTM). CONCLUSION: As pharmacy-based clinics continue to proliferate, pharmacists should carefully consider surrendering space in community pharmacies to other health care practitioners. These clinics present pharmacists with an opportunity to provide many of the additional health care services for which we have so vigorously argued. Failure to respond to the acute care needs of patients today may present pharmacists with a significant barrier as they continue to expand into direct patient care activities.

Pharmacists' and patients' roles in the pharmacist-patient relationship: are pharmacists and patients reading from the same relationship script?

BACKGROUND: Pharmacists' professional roles have maturated to include provision of information, education, and pharmaceutical care services. These changes have resulted in a focus on collaborative pharmacist-patient professional relationships, in which pharmacists and patients both have roles and responsibilities. OBJECTIVE: The study purpose was to investigate pharmacists' and patients' views of selected pharmacist and patient roles in the pharmacist-patient professional relationship, using principles of role theory. Pharmacist and patient role dimensions studied included (1) "information sharing,"(2) "responsible behavior," and (3) "interpersonal communication." "Creating a patient-centered relationship" and "active communication related to health care" were additional pharmacist and patient role dimensions studied, respectively. METHODS: Data were collected via mailed questionnaires from national random samples of 500 patients aged 18 years and older and 500 pharmacists. Internal consistency reliability was estimated for pharmacist and patient role dimensions using Cronbach's coefficient alpha and bivariate correlation analysis. Student's t test was used to compare pharmacists' and patients' views of role dimensions (alpha level of significance=.05). Descriptive statistics were used to characterize the pharmacist and patient samples. RESULTS: The adjusted response rates for the pharmacist and patient groups were 34.9% (173/496) and 40.8% (196/480), respectively. Pharmacist and patient role dimensions exhibited adequate reliability coefficients. Results showed that pharmacists and patients have similar views regarding pharmacists' "information sharing" roles in the relationship, but for the most part, patients agree less about pharmacists' "responsible behavior," "creating a patient-centered relationship," and "interpersonal communication" roles. Regarding patient roles in the relationship, pharmacists and patients have different views about patients' "information sharing," "responsible behavior," "interpersonal communication," and "active communication related to health care" roles. Results suggest that pharmacists more strongly agree that these are patient roles in the relationship than patients do. CONCLUSIONS: If pharmacists and patients agree on relationship roles, the functionality and outcomes of this relationship will be optimized. Future research is needed to monitor trends in pharmacists' and patients' views of their relationship roles and to develop strategies as needed to ensure that pharmacists and patients are following the same relationship script.

Market dynamics of community pharmacies in Minnesota.

BACKGROUND: From a pharmacist workforce perspective, an understanding of pharmacy location is important for monitoring access points for pharmacist services such as medication dispensing, medication counseling, medication therapy management, and disease management. OBJECTIVE: To understand access to community pharmacies, our goal was to describe changes in pharmacy mix (independent vs chain) between 1992 and 2002 for 87 counties in Minnesota. Study objectives were to describe the association of (1) change in population density, (2) metropolitan designation, change in (3) proportion of nonwhite population, (4) proportion of elderly population, and (5) household income with change in (a) number of community pharmacies overall, (b) number of chain pharmacies, (c) number of independent pharmacies, and (d) the independent-to-total community pharmacy ratio. METHODS: Records from the State of Minnesota Board of Pharmacy were used to examine changes in the community pharmacy mix from 1992 to 2002. Data on county level demographics in 1990 and 2000 were obtained from the US Census Bureau and Datanet. Chi-square analysis was used to test the relationships between the independent and dependent variables. RESULTS: As of 2002, every county in Minnesota had at least one pharmacy as was the case in 1992. The ratio of independent to chain pharmacies changed from approximately 2:1 in 1992 to approximately 1:1 in 2002. Chi-square results revealed that change in population density was significantly associated with change in the number of community pharmacies overall (P<0.001) and with change in chain pharmacies (P=0.03). The findings revealed an interesting u-shaped pattern for the association between population density and change in independent pharmacies. CONCLUSIONS: It appears that chain pharmacies follow changes in population density for making decisions about market entry and exit. The results suggest that some independent pharmacies might be closing due to chain competition in high population density growth areas. However, there was also evidence to suggest that population density decline may be an important determinant of independent pharmacy closures. In such environments, chain pharmacies are not likely to open new pharmacies to replace the independent pharmacy. Such a market dynamic may lead to access problems for citizens of these counties in the future.

Provision of risk management and risk assessment information: the role of the pharmacist.

BACKGROUND: There exists a need to conceptualize and understand the roles that pharmacists serve to help convince others such as patients, prescribers, and payers to value their contributions and to plan for the roles they could serve in the future within the health care system. OBJECTIVE: The purpose of this study was to (1) describe and track differences in pharmacists' and patients' views about the pharmacist's and physician's role in medication risk management and risk assessment in 1995, 1998, 2001, and 2004, and (2) describe associations between selected demographic variables and reported opinions about the pharmacist's role using data from 2004. METHODS: Brushwood's Risk Management/Risk Assessment Framework was used as a conceptual guide for developing 2 risk management and 2 risk assessment scenarios. For each scenario, study participants were asked to select the level of responsibility shared by physicians and pharmacists in addressing the drug therapy problem. Data were collected in 1995, 1998, 2001, and 2004 using random samples of pharmacists and patients as study subjects. Descriptive statistics and logistic regression analysis were used for analyzing the data. RESULTS: The results showed that pharmacists view their role as providing risk management information to patients and may view this role as adding value to patient care above and beyond a level that can be provided by a physician alone. In 2004, pharmacists started to view the risk assessment scenarios as being more their responsibility as well. Patients, on the other hand, consistently viewed their physician as having primary responsibility for their health care in all of the scenarios we studied. CONCLUSIONS: Pharmacists view their role as one that adds unique value to a patient's health through their provision of medication risk management and some types of risk assessment. However, patients do not yet view the pharmacist as the primary provider of either medication risk management or risk assessment information.

Patterns and predictors of prescription medication use in the management of headache: findings from the 2000 Medical Expenditure Panel Survey.

OBJECTIVE: The primary objectives were to examine national trends of prescription medication use for headache and explore patterns of variation in the use of these medications across social and demographic levels. BACKGROUND: Despite widespread use of prescription medication for management of headache, little is known about utilization patterns or patient characteristics associated with receiving this type of treatment. METHODS: This study conducted a secondary analysis of data obtained during the 2000 Medical Expenditure Panel Survey, a representative survey of the U.S. noninstitutionalized population. Weighted descriptive statistics and logistic regression models were used to evaluate patterns and rates of overall prescription medication use in patients reporting headache as a household condition. RESULTS: An estimated 9.7 million people 18 years or older reported suffering from headache in 2000. Of these, 46% reported using at least one medication for the treatment of headache. Migraine-specific abortive medication (ie, selective serotonin receptor agonists and ergotamine derivatives) was the most frequently reported medication class, used by 36% of participants. Opiate analgesics and butalbital-containing products also experienced extensive prescribing reported by 22% and 17% of survey respondents, respectively. After adjustment for covariates, wide variation in the use of prescription medication was observed across sociodemographic characteristics including age, ethnicity, and insurance status. CONCLUSION: The observed variation in prescription medication use by drug class and sociodemographic characteristics suggests strategies are needed for improving current prescribing patterns in this patient population.

The association of consumer cost-sharing and direct-to-consumer advertising with prescription drug use.

BACKGROUND: Previous research on the impact of various cost-sharing strategies on prescription drug use has not considered the impact of direct-to-consumer (DTC) advertising. OBJECTIVE: To explore the association of cost-containment strategies with prescription drug use and to determine if the association is moderated by DTC prescription drug advertising. METHODS: The study population included 288 280 employees and dependents aged 18 to 65 years with employer-sponsored health insurance contributing to the MEDSTAT MarketScan administrative data set. Person-level enrollment and claims data were obtained for beneficiaries enrolled continuously during July 1997 through December 1998. Direct-to-consumer advertising data were obtained from Competitive Media Reporting and linked to the MEDSTAT enrollment files. Localized DTC advertising expenditures for one class of medication were evaluated and matched with prescription claims for eligible MEDSTAT contributors. The association of various types and levels of cost-sharing incentives with incident product use was evaluated, controlling for the level of DTC advertising, health status, and other demographic covariates. RESULTS: The relationship of cost-sharing amounts with drug use was modified by the level of DTC advertising in a geographic market. This relationship was dependent on the type of cost-sharing, distinguishing between co-payments for provider visits and co-payments for prescription drugs. Compared with low-advertising markets, individuals residing in markets with high levels of advertising and paying provider co-payments of $10.00 or more were more likely to use the advertised product. In the same markets, higher prescription drug co-payments were associated with a decreased likelihood of using the advertised product. A similar relationship was not observed for the nonadvertised competitor. CONCLUSIONS: Among insured individuals, response to cost-sharing strategies is moderated by DTC prescription drug advertising. The relative ability of cost-sharing strategies to influence drug use should be interpreted with caution in the presence of DTC advertising.