Airborne laser-guided imaging spectroscopy to map forest trait diversity and guide conservation.

Functional biogeography may bridge a gap between field-based biodiversity information and satellite-based Earth system studies, thereby supporting conservation plans to protect more species and their contributions to ecosystem functioning. We used airborne laser-guided imaging spectroscopy with environmental modeling to derive large-scale, multivariate forest canopy functional trait maps of the Peruvian Andes-to-Amazon biodiversity hotspot. Seven mapped canopy traits revealed functional variation in a geospatial pattern explained by geology, topography, hydrology, and climate. Clustering of canopy traits yielded a map of forest beta functional diversity for land-use analysis. Up to 53% of each mapped, functionally distinct forest presents an opportunity for new conservation action. Mapping functional diversity advances our understanding of the biosphere to conserve more biodiversity in the face of land use and climate change.

Medication therapy in ambulatory medical care. National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey, 1992.

OBJECTIVES: This report describes medications provided or prescribed during ambulatory medical care visits in 1992. Total ambulatory care medication therapy combines data from office-based physicians, hospital outpatient departments (OPD's), and hospital emergency departments (ED's). Drug therapy is described along three dimensions: number of drugs provided or prescribed (drug mention), whether a visit had any drugs mentioned (drug visit), and average number of drugs mentioned per 100 visits (drug mention rate). Utilization in ambulatory care settings is compared in terms of patient, drug, provider, and visit characteristics. METHODS: Annual use of medication therapy was determined using data collected in the 1992 National Ambulatory Medical Care Survey (NAMCS) and the National Hospital Ambulatory Medical Care Survey (NHAMCS). NAMCS includes office visits to nonfederal physicians principally engaged in office practice. The target universe of NHAMCS includes visits to ED's and OPD's of non-Federal, short-stay, or general hospitals. Sample data were weighted to produce annual estimates. Drug mentions are defined as the number of drugs mentioned on the patient record from. RESULTS: An estimated 1.1 billion medications were provided or prescribed at ambulatory care visits in 1992. The setting with the greatest percent of visits with medication therapy was the ED; OPD's had the lowest percent with medications. Patients at the ED were provided more pain relief type drugs. The rate of drug mentions and percent of visits with medications were significantly higher in OPD clinics of general medicine and pediatrics compared with other types of OPD clinics. In office-based settings, physicians specializing in cardiovascular diseases were most likely to prescribe medications. Also, cardiovascular-renal type drugs accounted for the largest percent of office-based drug mentions. Visits with illness diagnoses are most likely to receive medication therapy. Trend data comparing 1980 to 1992 office-based mentions showed significant changes on several characteristics: single-ingredient drug status, physician specialty, and patient age. CONCLUSIONS: The profile of patients using office- and hospital-based ambulatory care settings are quite different as is the case-mix of conditions. These differences play an important role in medications utilized. The aging of the U.S. population from 1980 to 1992 appeared to have significant effects on several drug mention characteristics.

Ambulatory care visits for asthma: United States, 1993-94.

OBJECTIVE: This report describes ambulatory visits for asthma in the United States across three ambulatory care settings. The primary focus is on visits to office-based physicians. METHODS: The data sources include the National Ambulatory Medical Care Survey (NAMCS), a national probability survey of visits to office-based physicians in the United States, and the National Hospital Ambulatory Medical Care Survey (NHAMCS), a national probability survey of visits to hospital emergency and outpatient departments in the United States. Most estimates presented are annual averages for the 2-year period, 1993-94. Visits for asthma are defined as those for which asthma was the first-listed diagnosis. A trend analysis compares office visit data collected in 1993-94 to data in the 1980-81 NAMCS. RESULTS: There was an average annual estimate of 13.7 million ambulatory care visits for asthma in 1993-94, an annual rate of 53.4 visits per 1,000 persons. Four-fifth of ambulatory care utilization for asthma was conducted in physician offices. Relative utilization of office-based physicians was less for adolescent and black patients. The office visit rate for asthma increased 50 percent between 1980-81 and 1993-94. During 1993-94, use of office visits for asthma averaged 43 visits per 1,000 persons of 11 million office visits per year. The office visit rate in the Northeast was almost 2.5 times that in the South, although the prevalence of asthma was similar among regions. There were 5.8 return asthma visits for every new problem encounter. More than 40 percent of asthma visits had one or two comorbidities, mostly other respiratory conditions. Spirometry was used in 28 percent of asthma visits by new patients. Bronchodilators and anti-inflammatory agents were the most common medications prescribed. The use of corticosteroids and beta2-adrenergic agonists, either alone or in combination, increased substantially since 1980-81. The rate of utilization of methylxanthines decreased 61 percent between 1980-81 and 1993-94. CONCLUSIONS: The patient populations receiving care for asthma vary depending on the ambulatory care setting. Patients relying on hospital outpatient care for chronic asthma conditions may receive differential treatment and have different outcomes compared with patients of office-based physicians. For office-based ambulatory care, visits for asthma have increased substantially since 1980. Medication is the primary method of treatment with an increasing use of anti-inflammatory agents. The preferred bronchodilator has changed from methylxanthines to beta2-adrenergic agonists.

Antihypertensive drug use. Trends in the United States from 1973 to 1985.

Hypertension, a major public health problem, often requires drug therapy. We examined trends in outpatient antihypertensive drug use in the United States from 1973 to 1985. The numbers of prescriptions and the diagnostic and drug treatment information were obtained from the National Prescription Audit (Ambler, Pa, IMS America, 1985) the National Disease and Therapeutic Index (Ambler, Pa, IMS America, 1985), ongoing surveys of pharmacies, and office-based physicians. We adjusted drug-use data for the fact that several antihypertensive drugs also have other uses. During the study period, the annual numbers of prescriptions for treatment of hypertension progressively increased from 128.1 to 208.6 million, an average change of 5% per year. In 1973, the three leading classes of antihypertensive drugs were thiazide diuretic agents, peripheral neuronal inhibitors, and central alpha-adrenergic receptor stimulators. By 1985, the thiazide drugs were still the leader, followed by beta-adrenergic receptor blockers and potassium-sparing diuretic drugs. The use trends presented are consistent with surveys indicating increased drug therapy of hypertension from 1960 to the present.

Prescription drug use in 1984 and changes over time.

More than 1.5 billion prescriptions were dispensed from retail pharmacies in 1984 at a consumer cost of +18.4 billion. The number of prescriptions dispensed in 1984 equaled the previous record set in 1973. Over 40% of 1984 prescriptions were for four therapeutic classes: cardiovascular drugs, anti-infectives, psychotherapeutic drugs, and diuretics. Prescriptions for cardiovascular drugs and diuretics increased substantially from 1975 to 1984, while prescriptions for psychotherapeutic drugs decreased. Outpatient use of systemic antiinfectives remained fairly stable over the 10-year period. Trends in the use of specific drug categories within these broad therapeutic classes were variable, as were patient age and sex distributions.

A flexible module for teaching quality assurance and drug prescribing review concepts.

A case-approach, educational module is described that was designed with the necessary flexibility for teaching a variable number of quality assurance and drug prescribing review concepts to different types of students in different types of teaching situations. Module evaluation showed effectiveness as well as areas needing improvement.

Discovery of new adverse drug reactions. A review of the Food and Drug Administration's spontaneous reporting system.

Recently, several studies of spontaneous reporting systems (SRSs) have reported on the published literature's role in producing first reports of new adverse drug reactions. In order to provide further information on other components of SRS, the Food and Drug Administration's SRS was examined with regard to its effectiveness and efficiency in identifying new adverse drug reactions and the form, consistency, and timeliness of its communication of new adverse drug reactions to the medical community. While there was evidence that the literature was more effective in producing first reports of new adverse drug reactions for the years compared, there was reason to conclude that FDA's SRS was capable of making a contribution to the alerting process. Moreover, direct participation by practitioners in FDA's SRS was found to be the most efficiently obtained FDA source of new adverse drug reaction reports.

A method for post-marketing screening of adverse reactions to drugs: initial results.

The FDA is pilot-testing a methodology for signaling previously unsuspected relationships between drugs and important adverse events. This method uses data it receives through the FDA spontaneous reporting program. Reviewing drugs used primarily on an outpatient basis, this screening methodology focuses on "tracer" adverse events and the organization of these reactions into body/functional systems. This review process enables a clinical evaluator to perceive more easily the clinically important drug-adverse event patterns. The method can incorporate drug use data; this enables a drug's proportional share of specific adverse events, relative to its therapeutic class, to be compared to its respective proportional share of drug use. The assumption is that the adverse event distribution of drugs in a therapeutic class should be the same as the distribution of drug use in that class, if all drugs in the class were to carry the same risk. Actual examples of drug-adverse event associations signaled by the screening method are presented. The potential uses of this methodology in other settings, and under other data situations, are discussed.

Relationship of inappropriate drug prescribing to increased length of hospital stay.

The relationship of inappropriate drug prescribing to increased length of hospital stay was studied. The medical records of 77 cases of pyelonephritis were reviewed retrospectively. Appropriateness of antimicrobial drug therapy was judged by three types of explicit screening criteria: drug-specific, patient-specific, and match of drug to infecting organism. Patients whose therapy passed all the criteria were hospitalized, on the average, two days less than those whose therapy failed one or more of the criteria. This was a significant difference (p less than 0.05). Age, seriousness of the pyelonephritis, or method of payment appeared to have no significant moderating effect on this result. However, the increased length of stay may not have been associated with only inappropriate prescribing, because the inappropriately prescribing physicians kept their patients hospitalized longer beyond the point of symptom remission than did the appropriately prescribing physicians. The study suggest that successful interventions for improving drug therapy could result in large cost savings.

Can pharmacists influence drug prescribing? A look at eight of the top 25 drug products for 1976.

The most frequently prescribed drug products were reviewed for insights into prescribing and dispensing patterns for ambulatory patients. The indications for eight of the "top" drug products were considered to be pharmacologically or therapeutically questionable. The drug products were: tetracycline, systemic; Dimetapp; Empirin Compound with Codeine; Actified; Darvon Compound 65; Darvocet-N; Donnatal; and Keflex. Drug prescribing review and prescriber education are crucially needed, as well as formulary controls when feasible.

Low cost, manual drug use review of Medicaid recipients to screen prescriber and pharmacist performance.

A manual drug use review (DUR) methodology to screen outpatient prescribing which would meet the needs of large third-party programs that cannot afford elaborate computerized DUR was developed and pilot tested. A Medicaid drugs data base was used for the pilot test. A probability sample of 100 recipients over a three-month period was selected for the DUR. The drugs for each recipient, listed by their generic composition and amount, were recorded. Then a priori, explicit, screening criteria were developed for these generics. These criteria delineated drugs of choice, daily dose and refill patterns and, as appropriate, therapy length, drug holidays, and disease-drug and drug-drug interactions. Only 11% of recipients had prescribing patterns which passed all the screens. The most frequent screening failure was due to the prescribing of a drug which was not a drug of choice. In nearly all of the cases which failed the other screens, an alert pharmacist with patient records should have noticed these problems. An analysis showed that the initial start-up cost for the manual DUR was estimated at $1053 (not including personnel fringe benefits); for subsequent quarterly review, the cost was estimated to be about $530. The project showed that manual DUR can effectively and efficiently screen prescribing in a large third-party program.

Detecting prescribing problems through drug usage review: a case study.

A retrospective drug usage review was performed on 1,033 randomly sampled prescription orders from the outpatient pharmacy of a hospital and clinic system. Prescription orders were screened in accordance with criteria based on daily dosage, length of therapy or quantity dispenced, diagnosis, and labeling. The results of the study point to a number of potential prescribing problems. In addition, the study demonstrates the feasibility of collecting and analyzing drug usage data on a retrospective basis.

State-of-the-art of drug usage review.

Drug usage review (DUR) studies reported in 16 medical, allied health and pharmaceutical journals from 1970 to 1975 are analyzed. The studies cited included systematic data collection of prescription orders and an evaluation of these orders on at least one of the following: daily dose, length of therapy or quantity dispensed, or appropriateness of the drug itself. Gaps in both content and methodology of the DUR programs were discovered, and methods for improving future studies are discussed.