Pharmaceuticals in Medicare reform.

As policy makers explore ways to reform the Medicare system, the inevitable question of prescription drug coverage for the elderly will surface. This is an opportunity to revisit and balance the attractiveness of including a prescription benefit against the fear of increases in expenditures. Prudent examination of the costs and benefits of prescription drug coverage requires looking beyond pharmaceutical product costs.

Pharmaceutical research and development.

Some aspects of pharmaceutical research and development (R&D) are reviewed. The viability of major pharmaceutical manufacturers depends on their research and thus they commit substantial resources to R&D programs. Major pharmaceutical manufacturers in the United States employ about 40,000 R&D personnel, and worldwide pharmaceutical R&D expenditures reached $24 billion in 1990. The pharmaceutical industry is one of the most profitable; however, increasing prices of their products are often associated with increasing R&D costs, ignoring the many positive attributes of R&D. The Council on Competitiveness has recently proposed reforms in the approval process for new drugs, including accelerated approval, external review, and international cooperation. These reforms would help to preserve an R&D capability and a relatively unregulated pharmaceutical industry. Pharmaceutical R&D has made many important contributions, including increased life expectancy, the internationally competitive position of the US industry, and a positive balance of trade. However, a misunderstanding of the role of R&D could encourage development of policies and legislation detrimental to pharmaceutical R&D.

The elimination of selected drug products from the Michigan Medicaid formulary: a case study.

The purpose of this study was to evaluate the prescribing behavior, recipient response, and economic impact of the removal of selected prescription drug products from the Michigan Medicaid formulary. The frequency with which alternate legend drugs were prescribed and the frequency of continuous therapy via out-of-pocket cash were determined. From 17 independent Michigan pharmacies, a total of 137 patients with prescriptions for at least one eliminated drug product was identified. Of the Medicaid recipients on continuous therapy, 46% discontinued therapy. Over 23% had an alternate legend drug prescribed still covered under the Medicaid drug benefit. The alternate drug resulted in significantly higher acquisition costs. Over 30% of the recipients continued therapy at their own expense, representing a cost savings to the Medicaid program.

Impact of peer performance-evaluation on job satisfaction.

Job satisfaction in hospital pharmacists was measured before and after they participated in peer performance-evaluation (PPE). Job satisfaction questionnaires were administered to 35 staff pharmacists in three hospitals (a 500-bed hospital in Vermont and two Michigan hospitals of 234 and 446 beds). Items on the questionnaires reflected five facets of job satisfaction that directly relate to intrinsic reward and communication. Two weeks after the questionnaires were completed, peer performance-evaluation forms were distributed; subjects evaluated each of the other staff pharmacists at their hospital. Approximately six months later, peer performance-evaluation was repeated, followed by the posttest job satisfaction survey. The results of the PPEs were not divulged until after the posttest. Of the questionnaires returned, a matched sample of pretest-posttest questionnaires from 21 pharmacists was obtained. Analysis of the five facets showed that scores for two of the facets were significantly higher after PPE. PPE is one of many factors that may influence job satisfaction. In this limited study, certain aspects of job satisfaction seemed to increase after pharmacists participated in PPE.

Effect of pharmacist counseling on drug information recall.

The effect of counseling by pharmacists on patients' long-term recall of drug information was studied. Clinic and hospital neurological patients were counseled by a physician regarding a drug newly prescribed for them. Each patient in the study was then given a 15-item multiple-choice pretest specific for the new medication. Patients in the control group were given a posttest identical to the pretest eight weeks later. Test group patients were counseled by a pharmacist and were given the posttest eight weeks later. Specific information was categorized as to source. The mean scores of the test group patients increased 26.2 percentage points between pretest and posttest. Scores on information covered by the physician and reinforced by the pharmacist increased 19.6 percentage points, and scores on information presented only by the pharmacist with written reinforcement increased 30.6 percentage points. Scores of the control group patients showed no improvement between pretest and posttest. Pharmacist counseling had a significant effect on patients' recall of drug information after eight weeks.

Perceptions of work among men and women pharmacists in nonadministrative positions.

Perceptions of the types of duties performed by men and women hospital pharmacists in one section of a single state were studied, and differences in job attitudes that may be attributable to discriminatory job assignments are identified. A survey consisting of 153 questions was mailed to 507 pharmacists (328 men, 175 women, 4 whose sex was unknown) practicing in southeastern Michigan hospitals. Participants used a seven-point scale to rate the relative amounts of time they spent in various job activities. Activities were grouped as dispensing functions and clinical functions. Allotted time ratings for six clinical and six dispensing functions were averaged for each pharmacist. The survey used modules from the Michigan Organizational Assessment Questionnaire to measure pharmacists' perceptions of the quality of their work. Information from 279 questionnaires (60% men) was analyzed. No difference was evident in the perceived amounts of time men and women spent performing clinical activities. Women reported significantly greater time than men performing dispensing functions. Based on job dimensions, psychological states, and personal and work outcomes, a higher level of job satisfaction was expressed by men than by women. Men and women nonadministrative hospital pharmacists in this limited study perceived thier tasks differently.

Job content and pharmacists' job attitudes.

The relationships between job content and hospital pharmacists' work attitudes are examined. A 152-item questionnaire was mailed to 507 hospital pharmacists in southeastern Michigan. The questionnaire included measures of job dimensions, psychological states, and personal and work outcomes. Mean scores for 34 subscales consisting of 2-5 related items were computed. Background characteristics were also assessed. Using factor analysis, the respondents were categorized as clinical, inpatient, outpatient, or generalists depending on their reported relative time spent performing 23 nonadministrative job functions. Analysis of variance was performed across the four groups for each subscale; the level of significance was set at 0.001. The response rate was 56%, representing 283 completed questionnaires. The clinical, outpatient, inpatient, and generalist pharmacist groups consisted of 43, 36, 70, and 134 respondents, respectively. There was a prevalent trend in the rank order in which pharmacists in the four groups responded to various subscales. The clinical group had the highest scores for 13 of the 14 subscales that were significantly different across pharmacist groups. Alternatively, in all but one of the significantly different subscales the inpatient group ranked lowest. Because pharmacists in the clinical group consistently scored higher than the other groups on scales measuring components of job enrichment, the authors concluded that the challenge of hospital pharmacy managers is to adapt the positive features of clinical practice to other areas of the profession.

Perceived clinical significance of consultant pharmacist recommendations in the skilled nursing facility.

In an attempt to determine if pharmacists could make significant contributions to SNF patient care in the area of disease management, the drug therapy of the residents of two SNFs was reviewed once monthly for six months by two clinical pharmacist consultants. Pharmacist-identified problems and recommendations were communicated in writing to the medical staff by means of a communication form attached to the patient's chart. Nearly 72 percent of the recommendations made were accepted by the SNF physicians. Descriptions of the cases and corresponding recommendations were distributed to review-panel physicians. These physicians were asked to agree or disagree with the pharmacists' suggestions, and to rate the clinical significance of each recommendation using a modified Likert scale. The clinical pharmacist-consultants were perceived to have had a significant input into disease management in SNF patients.

Physician-, nurse-, and pharmacist-conducted patient drug histories.

A study was conducted in a 99-bed community hospital to determine quantitative differences in medication histories of selected patients conducted by pharmacists, nurses, and physicians. The hospital pharmacist documented more frequent patient medication usage than the nurse or physician. This study reaffirms the results observed by other investigators. The pharmacist, extensively trained and educated in the use and action of medications, should be considered a valuable resource in the documentation of drug use prior to hospital admission.

Pharmacist's effect on digoxin usage and toxicity.

Digoxin usage and toxicity were compared in a prospective group of patients who were monitored by a pharmacist and a retrospective group for which there was no pharmacist consultation. For the prospective group, the pharmacist monitored patients and estimated the steady-state digoxin levels by the use of a nomographic method. Level greater than 2.2 ng/ml and concurrent ECG or physical signs of digoxin toxicity were communicated to the physician. For the retrospective group, digoxin levels were calculated based on data from the patients' charts. The 49 patients in the two study groups were categorized according to four levels of digoxin toxicity (ranging from "no evidence" to "probable"). The only characteristic that was significantly different between the two groups was the calculated creatinine clearance (lower for the retrospective group). The maintenance dose of digoxin and the incidence of digoxin toxicity were significantly lower in the prospective group. It is concluded that pharmacist intervention may have had an effect in reducing digoxin dosage and toxicity.