Economic burden of influenza-like illness in long-term-care facilities.

Direct medical costs and medically related transportation costs incurred by patients in long-term-care facilities (LTCFs) as a result of influenza-like illness (ILI) were studied. The study was conducted from the payer's perspective. Charts were reviewed retrospectively for all patients who were residents of four Richmond, Virginia, LTCFs between January 1 and May 31, 1999. Consultant pharmacists gathered data on patient demographics, ILI status, vaccination for influenza and streptococcal pneumonia, diagnosis of asthma or chronic obstructive pulmonary disease, and utilization of health care services related to ILI. Services included the use of antimicrobials, antivirals, and respiratory drugs; emergency room visits; diagnostic tests; hospitalizations; and medically related transportation. Costs were based on average wholesale prices (for drugs) and Medicare or Medicaid reimbursement rates. Data were collected for 551 patients. Of these, 112 patients had been diagnosed with 128 cases of ILI during the study period. Twenty-two patients with ILI had 28 visits to emergency rooms, and 30 patients with ILI had 36 hospitalizations. The mean +/- S.D. cost per case of ILI was $1341 +/- $2063; inpatient hospital costs accounted for 84% of this amount. Centers for Disease Control and Prevention criteria for ILI provided a lower incidence of ILI and, consequently, a lower mean +/- S.D. cost of $968 +/- $1806 per case. ILI in patients in four LTCFs in Richmond, Virginia, generated substantial costs, the bulk of which resulted from hospitalization. A substantial percentage of the patients apparently were not immunized.

Changes in number and distribution of community and ambulatory pharmacies in Virginia from 1994 to 1999.

OBJECTIVE: To determine whether market changes have resulted in a decrease in the number or geographic distribution of pharmacies available to ambulatory patients in Virginia. DESIGN: Retrospective review of Virginia Board of Pharmacy records of pharmacy registrations in 1994 and 1999. SETTING: The Commonwealth of Virginia. PARTICIPANTS: All pharmacies classified as outpatient pharmacies (including community and other types of ambulatory pharmacies) and operating in Virginia in 1994 and 1999. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Changes in the total number, geographic distribution, and metropolitan/nonmetropolitan distribution of outpatient pharmacies between 1994 and 1999. RESULTS: The total number of outpatient pharmacies increased from 1,290 to 1,337 between 1994 and 1999. Chain pharmacies, mass merchandiser, and grocery pharmacies increased in number while independent pharmacies declined. There was little change in the geographic or metropolitan/nonmetropolitan distribution of pharmacies. CONCLUSION: Changes in the number and distribution of community and other ambulatory pharmacies in Virginia have not diminished their availability to consumers.

Quality of emergence from anesthesia and incidence of vomiting with remifentanil in a pediatric population.

UNLABELLED: We conducted a randomized trial to compare the incidence of vomiting and the quality of emergence from anesthesia associated with the use of remifentanil versus a nonopiate. It was expected that remifentanil would provide smoother emergence from anesthesia with a comparably low rate of vomiting. The study sample consisted of 115 pediatric patients undergoing dental restoration and extraction who were randomly assigned to the nonopiate or remifentanil groups based on their hospital admission numbers. The nonopiate patients received sufficient desflurane to prevent movement, typically 7%-9%. The remifentanil group received remifentanil 0.2 microg x kg(-1) x min(-1) and enough desflurane to prevent movement, typically 3.2%-3.6%. A trained postanesthesia care unit nurse, blinded to the anesthetic technique, assessed the quality of emergence and incidence of vomiting. Sixty-three patients received remifentanil and 52 received the nonopiate. The groups were not significantly different in either quality of emergence or incidence of vomiting. Remifentanil provided results comparable to a nonopiate with no increase in emesis. IMPLICATIONS: A randomized, controlled clinical trial of 115 patients undergoing dental restoration indicated that an anesthetic technique using remifentanil provided quality of emergence comparable to and no greater incidence of vomiting than a nonopiate technique.

Estimating a reasonable reimbursement for community pharmacies in third-party programs.

The purpose of this study was to estimate the level of reimbursement necessary to provide community pharmacies with a reasonable profit on prescriptions dispensed through third-party prescription programs. Data were gathered by means of a literature review and a survey of community pharmacies in Virginia. Results indicated that an average reimbursement of average wholesale price less 15% plus a $6.95 dispensing fee was needed to provide pharmacies with a reasonable profit. This is much higher than the reimbursements currently provided in most third-party prescription programs.

The effects of managed care on the retail distribution of pharmaceuticals.

The growth of managed care has resulted in substantial changes in the retail channel of distribution for pharmaceuticals. Community pharmacies' numbers and profit margins have declined, and marketshare has shifted to mail-service pharmacies as MCOs and pharmacy benefit managers have dictated reimbursement terms. Community pharmacies have consolidated to increase negotiating power and efficiency and have become more involved in direct patient care. The success of both MCOs and community pharmacies may depend on their ability to provide cooperative services that improve patients' health outcomes.

Economic evaluation of paroxetine and imipramine in depressed outpatients.

In this pilot study, we compared the economic impact of paroxetine and imipramine treatment of depressed outpatients from a university teaching hospital and a community mental health center. A 12-month retrospective chart review of patients was performed. Clinical outcomes including clinic usage, death, relapse, function, adverse effects, psychiatrist visits, and drug costs were evaluated. We analyzed drug costs, psychiatrist costs, and total direct costs using the Mann-Whitney U Test. The incidence of clinic usage, death, function, adverse effects, and psychiatrist visits was similar in patients treated with paroxetine (n = 12) and imipramine (n = 13). Two patients in the imipramine group were hospitalized once for a total of 5 days compared with none in the paroxetine group. Paroxetine drug costs were significantly higher than imipramine drug costs. Direct total costs (i.e., drug, psychiatrist visits, blood levels, and hospitalization costs) did not differ significantly between the groups based on actual drug usage (paroxetine: median $1,432.50 per patient per year; imipramine: median $1,425.81 per patient per year). Although the median direct total cost per patient per year for patients who received 12 months of therapy was lower in the paroxetine group ($1,479.90, n = 8) than the imipramine group ($1,503.61, n = 8), the difference was not significant. Our cost minimization analysis revealed no significant difference in the total cost between the two groups. However, the major cost in the paroxetine group was drug cost, whereas the major cost in the imipramine group was hospitalizations. Future large prospective trials are needed to validate these findings.

Outsourcing inpatient i.v. compounding: expense and medication error implications.

A quasi-experiment was conducted to evaluate differences in intravenous (i.v.) drug compounding costs and frequency of medication administration errors of omission before and after outsourcing the hospital's i.v. admixture refill program to an alternate site home i.v. infusion pharmacy. As part of the outsourcing changes, the pharmacy redeployed an i.v. admixture technician to do i.v. recycling on the nursing units. The study was a single subject, pretest, posttest (within subjects) design using an observer. The independent variables were outsourcing and having an i.v. recycling technician. The dependent variables were medication errors of omission and costs directly associated with the two i.v. programs. A statistically significant reduction in the frequency of medication administration errors of omission was associated with implementation of the outsourcing program. In addition, first year expenses were reduced by an estimated $86,356.

Profitability, third-party reimbursement, and access to community pharmacies.

The purpose of this study was to analyze the extent to which third-party reimbursement programs have affected the profitability and availability of community pharmacies. Data were taken from records maintained by the Virginia Board of Pharmacy and a survey of 177 community pharmacies. Between 1989 and 1994, 258 outpatient pharmacies opened and 342 closed. Chain and independent pharmacies suffered net losses, and supermarket and mass merchandiser pharmacies experienced net increases. Few significant changes occurred in the distribution of pharmacies over the study period. Fifty-nine chain and independent pharmacies and 1 supermarket pharmacy chain provided usable profit and reimbursement data. These pharmacies experienced declines in profits and increases in the percentage of prescriptions reimbursed by private third-party prescription programs over the last several years. Regression analyses indicated that higher ratios of sales of private third-party prescriptions to private-pay prescriptions were associated with lower profits. All respondents indicated that changes in private third-party reimbursement had substantially reduced profits over the past 5 years. The results indicate that the growth of private third-party payment has led to lower pharmacy profits but has not yet resulted in problems of consumer access.

Impact of generic and therapeutic interchange incentives on community pharmacy.

The purpose of this project was to estimate the increase in revenues that the average community pharmacy could expect from generic and therapeutic interchange bonuses provided by PAID Prescriptions, Inc.'s Coordinated Care Network. Data from the published literature and conversations with managed care experts and PAID employees were used to develop estimates for best-guess, worst-case, and best-case scenarios. Estimates were based on data from early 1994. It was estimated that the interchange bonuses would increase the average community pharmacy's revenues by an average $105 per year, a $0.55 increase in the dispensing fee. Best-case and worse-case estimates were $227 and $44 for increases in revenues. These were equivalent to $1.19 and $0.23 increases in the dispensing fee. Even with the most optimistic estimates, the total fee paid by the Coordinated Care Network (the sum of the dispensing fee plus interchange bonuses) is much less than the average pharmacy's cost of dispensing a third party prescription.

Postoperative nausea and vomiting after discharge from outpatient surgery centers.

We examined patients' experiences with nausea and vomiting after they were discharged from outpatient surgical centers. Data were collected on 211 surgical outpatients at 24-48 h after discharge via a telephone interview conducted by outpatient surgery nurses, and at 5 days after discharge via a patient-completed questionnaire. Telephone interviews were conducted with 193 patients. Questionnaires were completed by 154 patients. Over 35% of patients experienced postdischarge nausea and vomiting. Most had not experienced nausea and vomiting in the recovery room. The severity of nausea for these patients averaged 5 on a 10-point scale (10 indicating very severe nausea). During the 5 days after discharge, these patients reported experiencing nausea for an average of 1.7 days and vomiting for 0.7 days. Patients who experienced postdischarge nausea and vomiting were not able to resume their normal daily activities as quickly as those who did not. Patients managed postdischarge nausea and vomiting with little contact or intervention from health professionals and with minimal product purchases. The results indicate that postdischarge nausea and vomiting is common after outpatient surgery, and that it results in substantial distress and impairment for patients who experience it.

Costs incurred by outpatient surgical centers in managing postoperative nausea and vomiting.

STUDY OBJECTIVE: To estimate the financial costs incurred by outpatient surgical centers in managing postoperative nausea and vomiting (PONV). DESIGN: Prospective, observational study. SETTING: 6 hospital-based outpatient surgery centers. PATIENTS: 211 adult patients undergoing outpatient surgery for laparoscopy, dilatation and curettage, knee arthroscopy, or hernia repair. MEASUREMENTS AND MAIN RESULTS: Of the 211 patients studied, 34 experienced PONV in the recovery room. For those patients experiencing PONV, personnel, supply, and drug costs for management of this condition averaged $14.94 per patient. In addition, PONV increased the centers' operating costs by delaying patient discharge by an average of 24 minutes. A minimum estimate of this cost, based on nurses' wage rates, was $7.12. This estimate is appropriate only for short-run considerations in outpatient surgery centers that operate at low capacity. An appropriate valuation for long-run considerations and for centers operating near capacity is based on the revenue that centers lose as a result of extended stays. Lost revenue was estimated to be $415 per patient experiencing PONV. CONCLUSIONS: PONV substantially increases the costs incurred by outpatient surgical centers.

Effect of the prospective-pricing system on drug use in Pennsylvania long-term-care facilities.

Health status, nondrug treatment, and drug use were compared for patients discharged from hospitals to seven long-term-care facilities (LTCFs) in Pennsylvania before and after implementation of the prospective-pricing system (PPS) for hospitalized Medicare patients. Data were collected from medical records of LTCF patients for August 1982 through July 1983 (pre-PPS) and August 1985 through July 1986 (post-PPS). Patients in the post-PPS group (n = 297) had greater numbers of illnesses and more serious illnesses on admission to the LTCFs and were more likely to be readmitted to hospitals than pre-PPS patients (n = 312). Patients in the post-PPS group required more nondrug treatments such as urinary catheters, nutritional supplements, and oxygen and received significantly more drug therapy. The cost of drugs was 50% higher in the PPS group. The post-PPS patients admitted to the LTCFs apparently required more posthospital drug and non-drug therapy than the pre-PPS patients. Any system for prospective pricing in LTCFs should take into account the increases in costs for providing long-term care, including drug therapy, that have occurred since prospective pricing for hospitalized patients began.

Inherent risk and market acceptance of generic drug products.

The results of a national survey of pharmacists indicate that generic substitutes are less likely to be used for drugs with higher inherent risk. Drugs used to treat chronic disease conditions are viewed as high risk products. Those used to treat symptoms are considered low risk products.

Influence of age, sex, and race on prescription drug use among Georgia Medicaid recipients.

Interactions among patients' age, sex, and race that influence prescription drug use in a state Medicaid population are described. A database containing information about all 574,762 Medicaid prescriptions dispensed in Georgia during December 1985 was sorted and summarized so that each record represented one Medicaid recipient. The following data were included for each recipient: the total number of Medicaid prescriptions received by that patient during that month, the total payments made by the state for those prescriptions, and the patient's age, sex, and race. Analyses were conducted on a 10% random sample representing 17,128 patients. The age variable was broken down as follows: Child, 0-5 years; Youth, 6-23 years; Adult, 24-64 years; and Old, 65 years of age or older. Race was recorded as white or nonwhite, and sex as male or female. The average white patient received significantly more prescriptions than did the average nonwhite patient. The largest percentage (41.6%) of the patients in the sample were classified as Old, and this group received the greatest mean number of prescriptions. The differences between mean numbers of prescriptions for white and nonwhite patients increased as the age of the patients increased. Gender influenced drug use only through its interaction with age and race. Patients in the white female Old category had the greatest mean number of prescriptions per patient, and patients in the nonwhite male Youth category had the fewest. The peak period of prescription drug use occurred between the ages of 70 and 80 years, and thereafter use decreased. In this Medicaid population a patient's age and race significantly influenced the number of prescription drugs that he or she used.

Comparison of job expectations fulfillment of BS and entry-level PharmD graduates in hospital and community practice.

Job expectations are an important link between work and subsequent employee mental and physical well-being. Schools and colleges play an important role in the development of job expectations. This role gives them the responsibility of not only technically training students but also instilling in them realistic job previews and career expectations. Failure to do so places the graduate in a state of conflict between the reality of work in his/her chosen career and his/her preconceived expectations regarding the work. This state represents a potential source of job-related stress. BS and entry level PharmD training programs represent two approaches to pharmaceutical education in a practice environment which remains essentially the same for graduates of both programs. As such, there is the potential for a mismatch of job expectations resulting from one or both of the degree types. The present study investigated the following research questions: (i) to what extent are job expectations being fulfilled for pharmacists in hospital and community pharmacy; and (ii) in community and hospital practice, does the fulfillment of job expectations of BS and entry level PharmD graduates differ? Questionnaires were mailed to randomly selected 1980 to 1986 graduates of seven schools or colleges of pharmacy to elicit responses regarding fulfillment of job expectations in their present community or hospital pharmacy positions. The response rate was 48 percent. The subsequent data revealed that pharmacists generally felt that their job expectations were being fulfilled. No differences in overall fulfillment of job expectations were found between BS and entry level PharmD graduates in either community or hospital pharmacy practice.(ABSTRACT TRUNCATED AT 250 WORDS)

A comparative study of current Medicaid prescription reimbursement (MAC/EAC) (maximum allowable cost/estimated acquisition cost) with prescription reimbursement based on a competitive market.

Many pharmacists have suggested that the current Maximum Allowable Cost/Estimated Acquisition Cost (MAC/EAC) program has departed from its intended purpose of generating savings by taking full but fair advantage of the competitive marketplace. The objective of this study was to compare Medicaid prescription reimbursement under current MAC/EAC regulations with prescription reimbursement based on a competitive market. Data representing the top selling single source and multiple source drug products for nine states were analyzed. Results indicated that the current MAC/EAC system of Medicaid reimbursement produced a small savings when compared to reimbursement based on a competitive market.

Comparison of practice patterns and job satisfaction of entry level PharmD and BS level graduates in hospital and community practice.

Controversy has and continues to exist over whether schools of pharmacy should make the PharmD the universal entry level pharmacy degree. Proponents argue that doctorate status would enhance pharmacy's professional image and society would benefit from doctoral-level training. Opponents counter that, given the present health care system, society can place only a small percentage of pharmacists in positions requiring training at the doctorate level and, further, placing pharmacists with highly developed clinical skills in positions not requiring such skills will lead to both frustration and loss of clinical skills. The present study investigated the following research questions with regard to community and hospital pharmacy practice: (i) do job activities of entry level PharmD graduates differ from those of BS graduates; and (ii) does the job satisfaction of entry level PharmD and BS graduates differ? Questionnaires were mailed to randomly selected California entry level PharmD graduates and Georgia BS graduates to elicit responses regarding practice patterns and job satisfaction. Response rates were 68 percent for PharmD and 62.5 percent for BS respondents. The subsequent data revealed that both PharmD and BS respondents devoted the greatest portion of their time to drug distribution in both practice settings. Minimal differences were noted in other work activities in either on practice setting. No differences in job satisfaction were found.