Developmental and behavioral consequences of prenatal cocaine exposure: a review.

Substance use among pregnant women continues to be a major public health concern, posing potential risk to their drug-exposed children as well as burdens on society. This review is intended to discuss the most recent literature regarding the association between in utero cocaine exposure and developmental and behavioral outcomes from birth through adolescence across various domains of functioning (growth, neurobiology, intelligence, academic achievement, language, executive functioning, behavioral regulation and psychopathology). In addition, methodological limitations, associated biological, sociodemographic and environmental risk factors and future directions in this area of research are discussed. Given the large number of exposed children in the child welfare system and the increased need for medical, mental health and special education services within this population, more definitively documenting associations between prenatal cocaine exposure and later child outcomes is essential in order to be able to prospectively address the many significant public health, economic and public policy implications.

Psychometric evaluation of the 12-item short-form health survey (SF-12) in osteoarthritis and rheumatoid arthritis clinical trials.

BACKGROUND: The psychometric properties of the 12-Item Short-Form Health Survey (SF-12), a subset of the Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36), have been tested in the general population and certain disease states. OBJECTIVE: The purpose of this study was to evaluate the psychometric properties of the SF-12 as a generic measure of health-related quality of life (HRQoL) in osteoarthritis (OA) and rheumatoid arthritis (RA) patient populations in clinical trials. METHODS: Data were aggregated from 5 clinical trials evaluating the efficacy of non-steroidal anti-inflammatory drugs in OA (n = 651) and RA (n = 693) patients. Patient assessments in these trials were made using the SF-36 and commonly used clinical measures of OA and RA at baseline and after up to 6 weeks of treatment. For the items of the SF-36 contained in the SF-12, the item missing rate, computability of scores, floor and ceiling effects, factor structure, and item-component correlations were evaluated. Clinical variables and correlations of physical component summary (PCS-12) and mental component summary (MCS-12) scores of the SF-12 with the corresponding SF-36 component summary scores (PCS-36 and MCS-36) were also examined. Analyses were conducted separately for OA and RA patients. RESULTS: A low individual SF-12 item missing rate (0.29% to 2.30%) and a high percentage score computability (90.9%-94.3%) were observed at baseline. No floor or ceiling effects at baseline were observed. The scree plot confirmed the 2-factor structure of the SF-12 items. Items belonging to the physical component correlated more strongly with the PCS-12 than with the MCS-12; similarly, items belonging to the mental component correlated more strongly with the MCS-12 than with the PCS-12. The correlations between the PCS-12 and PCS-36 and between the MCS-12 and MCS-36 ranged from 0.92 to 0.96 (P < 0.001) at baseline and at week 2, 4, or 6. Significant correlations ranging from -0.09 to -0.58 (P < 0.05) were observed between the SF-12 scores and clinical variables. CONCLUSION: The SF-12 appears to be a psychometrically sound tool for the assessment of HRQoL in OA and RA patients.

Effect of orthographic and phonological similarity on false recognition of drug names.

Health professionals and patients tend to confuse drugs with similar names, thereby threatening patient safety. One out of four medication errors voluntarily reported in the US involves this type of drug name confusion. Cognitive psychology offers insight into how and why these errors occur. The objective of this investigation was to examine the effect of orthographic (i.e., spelling) and phonological (i.e., sound) similarity on the probability of making recognition memory errors (i.e., false recognitions). Prospective, computer-based, recognition memory experiments on 30 pharmacists and 66 college students were conducted. Participants viewed a study list of drug names and then a test list. The test list was twice as long as the study list and contained distractor names at progressively increasing levels of similarity to the study words. The task was to identify which test names were on study list and which were new. The main outcome measure was probability of making a false recognition error (i.e., of saying a new name was on the study list). Among pharmacists and college students, there was a strong and significant effect of similarity on the probability of making a false recognition error. It was concluded that both orthographic (i.e., spelling) and phonological (i.e., sound) similarity increase the probability that experts and novices will make false recognition errors when trying to remember drug names. Similarity is easily and cheaply measured, and therefore, steps should be taken to monitor and reduce similarity as a means of reducing the likelihood of drug name confusions.

Arthritis care: comparison of physicians' and patients' views.

OBJECTIVES: To understand the expressed needs of physicians and their patients with respect to arthritis care, identify areas of agreement and disagreement in doctor and patient views of arthritis care, and to determine the types of educational programs needed. METHODS: Focus group interviews were conducted with 14 physicians of varied specialties and 12 patients with arthritis from Oxford Health Plans. Interviews were audiotaped and transcribed. Analyses were performed by using text processing programs from the Unix computer operating system. Common themes were identified and summarized. RESULTS: Physicians and patients agreed that pain and loss of functioning were the most important problems patients with arthritis faced and that arthritis was incurable. Both agreed that doctors need more time to discuss individual concerns with their patients. More information about diet and exercise and strategies for reducing social isolation were needed. Doctors and patients disagreed about the value of nutritional supplements, joint replacement, and referrals to specialists. Disagreement also existed regarding the belief that pain was an inevitable part of the aging process, and with respect to the use of drug and surgical therapy. CONCLUSIONS: Areas of agreement and disagreement were discussed. Collaboration and negotiation were identified as constructive responses to conflicts between physicians and patients. Patients need to be taught self-care strategies to minimize the impact of arthritis on their daily lives. The specific continuing education needs of physicians involved training in exercise, nutrition, occupational and physical therapy, prescriptions, and alternative medicine.

Similarity as a risk factor in drug-name confusion errors: the look-alike (orthographic) and sound-alike (phonetic) model.

BACKGROUND: One of every four medication errors reported in the United States is a name-confusion error. The rate of name-confusion errors might be reduced if new and confusing names were not allowed on the market and if safeguards could be put in place to avoid confusion between existing names. OBJECTIVES: To evaluate several prognostic tests of drug-name confusion, alone and in combination, with respect to their sensitivity, specificity, and overall accuracy. RESEARCH DESIGN: Case-control study. Twenty-two different computerized measures of orthographic similarity, orthographic distance, and phonetic similarity were used to compute similarity/distance scores for n = 1,127 cases (ie, pairs of names that appeared in published error reports or national error databases) and n = 1,127 controls. MAIN OUTCOME MEASURES: Mean similarity/distance scores were compared across cases and controls. The performance of each measure at distinguishing between cases and controls was evaluated by tenfold crossvalidation. Dose-response relationships were examined. Univariate and multivariate logistic regression models were formed and evaluated by 10 fold crossvalidation. RESULTS: Cases had significantly higher similarity scores than controls. Every measure of similarity proved to be a significant risk factor for error. There was a significant increasing trend in the odds-ratio as a function of similarity. A three-predictor logistic regression model had crossvalidated sensitivity of 93.7%, specificity of 95.9% and accuracy of 94.8%. CONCLUSIONS: A sensitive and specific test of drug-name confusion potential can be formed using objective measures of orthographic similarity, orthographic distance, and phonetic distance.

Patient counseling--a focus on maintenance therapy.

Pharmacist counseling of patients receiving long-term medications for chronic diseases is discussed. Patient counseling should be viewed as one component of the overall drug-use process. Pharmacists counseling patients prescribed long-term medications need to understand the lifestyle effects of chronic illness, particularly the different types of "work" the chronically ill patient must undertake. Pharmacists need to go beyond traditional sender-message-receiver communication models in counseling patients and to adopt a problem-solving approach through which each patient's needs and level of understanding are taken into account. Patients should be actively involved in their therapy decisions. Patients will be at varying stages in terms of making any behavioral changes needed to maximize therapeutic outcomes, and counseling must be adapted to fit the stage of change. The Indian Health Service (IHS) model of counseling uses open-ended questions to determine patients' knowledge of their disease and medications; this enables the pharmacist to fill in any gaps and review specific points. The health communication model provides strategies for enhancing patient compliance and recall and complements the IHS model. In practice, the techniques used will depend on whether the patient is a new-prescription patient or an established patient. The models can be adapted to counseling care-givers and can be complemented by compliance aids. The demand for pharmacist counseling of patients with chronic illnesses is likely to increase, and, to effectively counsel patients about long-term medication use, pharmacists need to appreciate the personal impact of chronic illness beyond the direct effects of the biomedical disease itself, and must understand modern communication models.

Predicting look-alike and sound-alike medication errors.

A model for predicting medication name confusion is described. Many medication errors are caused by look-alike and sound-alike medication names, yet few procedures exist to ensure the safety of new drug nomenclature or to identify confusingly similar names from within existing databases. In this study, three automated, quantitative measures of orthographic similarity (i.e., similarity in spelling) were identified (bigram similarity, trigram similarity, and Levenshtein distance). The relationship between orthographic similarity and the likelihood of a medication error was examined. For each measure of similarity, the frequency distribution of similarity scores for pairs of drug names previously reported to cause confusion (error pairs) was compared with the distribution of similarity scores for control pairs randomly selected from the general index of USP DI-Volume I: Drug Information for the Health Care Professional. Then, three parallel, unmatched case-control studies were conducted to discover whether similarity was a significant risk factor for medication errors. Finally, on the basis of the three similarity measures, tests for predicting confusion were developed and evaluated. For each similarity measure, the frequency distribution of error pairs was significantly different from that for control pairs, and orthographic similarity was a significant risk factor for medication errors. Pairs of names whose measures of similarity exceeded present thresholds were between 25 and 523 times more likely to be involved in a medication error than pairs whose similarity did not exceed these thresholds. A prognostic test that correctly identified 91% of all pairs as either errors or controls was developed. This test had a sensitivity of 84% and a specificity of 99%. Automated measures of similarities between medication names can form the basis of highly accurate, sensitive, and specific tests of the potential for errors with look-alike and sound-alike medication names.

Factors associated with antibiotic prescribing in a managed care setting: an exploratory investigation.

This multi-site, cross-sectional, observational study sought to identify attitudinal and social normative factors associated with the prescribing of oral antibiotics to ambulatory patients in a managed care setting. Participants were 25 physicians specializing in internal medicine, family practice or pediatrics from five ambulatory care clinics within a large, fully integrated health care system in a major midwestern U.S. city. The main outcome measure was number of prescriptions per physician written in the fourth quarter of 1994 for each of seven selected antibiotics. Correlational and multiple regression analyses revealed that behavioral intentions were significantly associated (P < 0.05) with both attitudes and subjective norms. However, physicians' attitudes, subjective norms and intentions were not predictive of actual antibiotic prescribing behavior. Prescribing behavior may have been a function of patient-specific rather than general beliefs about antibiotics. Methodological limitations related to the sample size and the sparseness of the utilization data may also have prevented a significant effect of intentions on behavior from being detected. Alternatively, in managed care settings, it is hypothesized that prescribing behavior may have been influenced more by non-psychological factors, such as management systems, formularies and therapeutic substitution programs, than they were by internal, psychological factors such as attitudes, subjective norms and intentions. Managed care is altering the role of the physician as an autonomous decision-maker. In response, models of prescribing must either incorporate variables such as perceived behavioral control to aid in the prediction of non-volitional behavior, model the decision-making of non-physician managers, or forego psychological models in favor of structural or system-level models of drug utilization.

Face and politeness in pharmacist-physician interaction.

This study used Brown and Levinson's theory of politeness to gain a better understanding of the factors that influence pharmacists' messages to physicians. Specifically, perceived differences in power and social distance between pharmacist and physician were expected to influence the amount of politeness observed in pharmacists' messages. The effects of age, sex and practice context were also examined. Written messages were gathered from 210 community pharmacists and 112 hospital pharmacists in response to a hypothetical drug allergy scenario. Messages were segmented into independent clauses, and independent clauses were classified according to the politeness strategy used to make allergy reports and alternative drug recommendations respectively. Content analysis of the messages in relation to demographic variables revealed that age and practice context were significantly associated with the overall level of politeness of alternative drug recommendations, but not with overall politeness of allergy reports. Demographic factors were significantly related to perceptions of power and social distance, but, contrary to Brown and Levinson's prediction, these perceptions were not associated with variation in politeness. Regardless of other factors, recommendations were made more politely than reports. Implications for pharmacists' professional roles and identities are discussed.

Directness and deference in pharmacy students' messages to physicians.

The profession of pharmacy is in the midst of an attempted role expansion. Advocates of a philosophy of practice known as pharmaceutical care want to expand the traditional role of the pharmacist to include patient counseling, drug use monitoring, clinical consultation with physicians, and responsibility for patient outcomes. Other health professions are resisting this role expansion, and it has proven difficult to socialize students into a professional role that is not yet widely accepted. To better prepare students for the workplace, pharmacy educators need a way of assessing the extent to which students have accepted and begun to enact the expanded clinical role. Since role and identity disputes are negotiated in routine interactions between pharmacists and other health professionals, an assessment tool was devised to mimic a common interprofessional interaction. Written messages to physicians were gathered from pharmacy students in response to a hypothetical drug allergy scenario. Pharmacist-physician communication is especially problematic because many of the acts pharmacists routinely perform (e.g. correcting, reminding, reporting, etc.) are intrinsically threatening to a physician's professional identity and sense of self worth. Brown and Levinson's politeness theory explains how situational factors influence peoples' choices in dealing with such identity threatening acts. As an act becomes more threatening, the degree of politeness accompanying the act also increases. Detailed content analysis of pharmacy students' messages to physicians determined that allergy reports were more likely to be made directly than alternative drug recommendations. Recommendations were more likely than reports to be omitted entirely. Implications for pharmacy students' emerging professional identities are discussed.