Consumer participation in health policy decisions: empowerment or puffery?

Many consumers in today's society have increased access to information about health and medical care through books, videotapes, audiotapes, the Internet, and television programming. However, consumers often are excluded from involvement in health policy decision making because it is believed that they do not have the necessary expertise. In this paper, the following will be discussed: (1) the historic role of consumer involvement in health policy decision making, (2) an overview of major barriers that consumers have encountered in health policy decision making, and (3) strategies for overcoming these barriers so that consumer empowerment can be enhanced when they serve on health policy panels.

Understanding and addressing racial disparities in health care.

Racial disparities in medical care should be understood within the context of racial inequities in societal institutions. Systematic discrimination is not the aberrant behavior of a few but is often supported by institutional policies and unconscious bias based on negative stereotypes. Effectively addressing disparities in the quality of care requires improved data systems, increased regulatory vigilance, and new initiatives to appropriately train medical professionals and recruit more providers from disadvantaged minority backgrounds. Identifying and implementing effective strategies to eliminate racial inequities in health status and medical care should be made a national priority.

Computerized prescribing: building the electronic infrastructure for better medication usage.

Computerized prescribing in the practice of medicine is a change that is overdue. Virtually all prescriptions in the United States are still handwritten. Instead, medications should be ordered on a computer interacting with 3 databases: patient drug history, scientific drug information and guideline reference, and patient-specific (weight, laboratory) data. Current problems with prescribing on which computerized prescribing could have a positive impact include (1) drug selection; (2) patient role in pharmacotherapy risk-benefit decision making; (3) screening for interactions (drug-drug, drug-laboratory, drug-disease); (4) linkages between laboratory and pharmacy; (5) dosing calculations and scheduling; (6) coordination between team members, particularly concerning patient education; (7) monitoring and documenting adverse effects; and (8) postmarketing surveillance of therapy outcomes. Computerized prescribing is an important component of clinician order entry. Development of this tool has been impeded by a number of conceptual, implementation, and policy barriers. Overcoming these constraints will require clinically and professionally guided vision and leadership.

Drug and therapeutics committees: the relationships among structure, function, and effectiveness.

Reported are the results of a national study of Australian hospitals that assessed the effectiveness of drug and therapeutics committees (DTCs), identifies factors that influence effectiveness, and recommends methods to improve effectiveness. Data were collected by questionnaires sent to 184 hospital directors of pharmacy and a subset of 53 chairpersons of DTCs. Response rates were 88.6% and 84.9%, respectively. Membership, chairperson, secretary, meeting frequency, and decision-making functions were analysed by hospital bed numbers and compared with standard accepted literature criteria and previous study findings. A comparison of pharmacist and chairperson perception as to the weakest aspect of DTCs in attaining rational therapy revealed widely differing views, based on factors outside respondents' own control. Perceptions of resources required to overcome DTC weakness also varied between the two groups. No statistically significant association was found between the assessment of outcome of DTC activities (influence on pharmacy management, hospital policy, medical management, and prescribing) and structural variables such as DTC objectives, chairperson, reporting relationship, meeting frequency, and hospital size or type. The results challenge widely held assumptions of the association between DTC effectiveness and structural variables. Further study of structural and cultural variables, which might determine effectiveness, is required.

Drug formularies: myths-in-formation.

Drug formularies are pivotal tools for delineating and directing prescribing to the "drugs of choice." Full realization of their potential has been hampered by insufficient comparative data on drug efficacy/safety and local resources for formulary development. However, misconceptions concerning fundamental formulary concepts pose an even more formidable obstacle. This article identifies statements illustrating formulary misconception a) made by physicians attending Pharmacy and Therapeutics Committee meetings during a three-year period and b) appearing in published sources. The paper highlights basic objectives and operational requirements of an effective formulary, and contrasts this definition with 20 myths and misinformation culled from these two sources. Not only does such misinformation impair formulary development, many critics are so preoccupied with alleged shortcomings that progress in minimizing the real limitations of formularies has been impeded.

Prescribing for unlabeled conditions: patient benefit or therapeutic roulette?

There is ample evidence that prescribed medications are employed for uses far broader than the approved label indications in the U.S. An enormous research agenda thus exists that should be addressed in the not-too-distant future. In fact, it seems essential that operation of the Medicare Catastrophic Drug Benefit program be designed with the best available knowledge in this area. Perhaps it might be appropriate for several universities, the U.S. Pharmacopeial Convention, and/or the FDA to establish a center to study this question. This model has been applied with clinical/surgical registries, with adverse reaction reporting, and with device failures. We need a rational, science-compatible, and uniform policy free of political and emotional arguments to address the issue of handling, monitoring, and regulating the use of drugs for unlabeled conditions. Comprehensive data should be provided for policy makers, regulators, payers, and clinicians in their evaluating the use of different drug products. Even a brief glance at any page from the National Disease and Therapeutic Index shows intended use that would cause most experts to react in disbelief. Further, there seem to be relatively few instances in which the use of a given pharmaceutical for an unlabeled indication would qualify as a drug of choice in the first place. The therapeutic and economic consequences of the use of legend drugs for unlabeled indications are difficult to document. We do know that a significant proportion of hospital admissions and days can be traced to the inappropriate use of pharmaceutical products but the net impact of our subject on institution cost has not been established.(ABSTRACT TRUNCATED AT 250 WORDS)

Pharmacy's role in the evolving health care system: quality, cost but mostly access.

Access to pharmacy services represents one of the key elements in the operation of our health care delivery system. Major conceptual aspects of access are outlined. Two issues related to the supply side of our basic economic equation, product availability and pharmacy resources, are discussed. A model for obtaining comprehensive manpower data to support educational, professional and public policy needs is also proposed. In order to appraise the demand for pharmaceutical products and professional services, data on Medicaid drug expenditures is reviewed and perplexing questions regarding use characteristics are treated.

Quality control of hospital formularies.

This paper identifies various uses of the formulary concept, outlines factors that underlie the need for such an administrative device, and reviews four barriers to effective formulary control. It then examines selected components of the formulary system and specifies the need for supporting techniques, both internal and external. Twelve guidelines for developing a model drug formulary are presented. While administrative elements associated with implementation of a formulary are stressed, concerns about more intangible behavioural forces are introduced.

Problem solving: the professional responsibility of pharmacists.

This paper outlines a method by which pharmacists may invoke external assistance to help minimize patient risk not readily controlled at the treatment level when prescription therapy is authorized. This complex mechanism, the alarm model, identifies potential change agents and suggests intervention options that may be employed to activate an appropriate support system. Possible limitations of the innovative concept are also treated.