Growth factor usage patterns and outcomes in the community setting: collection through a practice-based computerized clinical information system.

PURPOSE: Although use of colony-stimulating factor (CSF) is widespread and guidelines for use have been disseminated, actual practice patterns of medical oncologists are unknown. The purpose of this study was to collect these data using an office-based computerized clinical information system. PATIENTS AND METHODS: Data were collected on patients at 10 community-based oncology practices. Information regarding CSF use was captured at the time of prescribing through a computerized clinical support tool and stored in a data warehouse, and an analysis was carried out retrospectively. RESULTS: A total of 6,813 cancer regimens administered to 5,034 patients were evaluated for growth factor use. Overall, CSFs were used in 14% of regimens, with breast, lymphoma, lung, and ovarian being the most common cancers for which CSFs were used. In 49.4% of regimens, CSF was initiated during cycle 1, with an average duration of 1 week, and was used in two or three cycles per regimen. Afebrile neutropenia is rarely followed by CSF initiation. Granulocyte colony-stimulating factor (G-CSF) is associated with fewer dose adjustments, delays, and hospitalizations when compared with granulocyte-macrophage colony stimulating factor (GM-CSF). There is wide variation among oncologists in CSF use, and several substantial differences were noted between the prescribing behavior of American Society of Clinical Oncology (ASCO) survey-reported oncologists and actual clinical practice, as captured by the computerized clinical information system. CONCLUSION: Computerized clinical information systems can collect detailed information regarding practice patterns of medical oncologists. ASCO physician practice survey data do not accurately reflect actual practice patterns and must be interpreted with caution. Substantial deviations from ASCO growth factor guidelines remain, and oncologists' use of CSFs demonstrates wide variation. There may be important clinical differences between G-CSF and GM-CSF, but definitive phase III trials are needed for confirmation.

Complications of home parenteral nutrition.

The complications associated with home parenteral nutrition (HPN) and their relationship to length of therapy were studied. The medical records of 56 patients treated with HPN (age range, 6 months to 82 years) were retrospectively reviewed to study complications associated with HPN. Of the 56 study patients, 30 (53.6%) had complications related to HPN, 18 (32.1%) had complications not related to HPN, and 8 (14.3%) had no complications. Of the 365 total complications noted, 125 (34.2%) were related to HPN. The mean +/- S.D. interval between initiation of HPN and occurrence of a complication was 1.25 +/- 1.73 years (mean +/- S.D.). Patients were more likely to have fluid or electrolyte complications or glucose intolerance in the first year of therapy and catheter-related complications later in the course of treatment. The first episode of septicemia occurred 2.1 +/- 1.8 years (mean +/- S.D.) after the initiation of HPN. The risk of developing catheter-related septicemia was higher for patients on long-term HPN therapy and for young patients. Patients receiving HPN should be carefully monitored for complications such as fluid and electrolyte abnormalities and glucose intolerance, which commonly occur early in the course of therapy; later complications of HPN include catheter-related infection, thrombosis, and breakage or dislodgement.

Experience with selective reporting of susceptibility to antimicrobial agents.

Experience with a system of selective and hierarchical reporting of susceptibility to antimicrobial agents in the hospital setting is described. In March 1985 and January 1987 the medical records of all patients with susceptibility test results were reviewed; there were a total of 488 susceptibility reports. Antimicrobial therapy was evaluated for appropriateness on the basis of the reported susceptibility test results. Susceptibility reports would not have affected the choice of antimicrobial agents in the majority of cases because patients had already been discharged, infection had not been documented, or appropriate therapy had already been started. In approximately 40% of cases in which susceptibility reports could have influenced prescribing, physicians chose appropriate initial therapy after susceptibility results became available. If only the instances in which susceptibility reports could have influenced prescribing are considered, then therapy was appropriately changed 12.5% of the time in March 1985 and 24.2% of the time in January 1987. Selective reporting of susceptibility to antimicrobial agents should be viewed as an adjunct to, not a substitute for, other interventions to promote appropriate prescribing in cases of infection.

Survey of home nutritional support patients.

Patients receiving home parenteral nutritional services from a major corporate provider were surveyed using a written questionnaire. The survey questioned the patients about use of home parenteral nutritional services and the quality of life while receiving home parenteral therapy. Patient satisfaction with home nutritional support services, and the impact home therapy has on patient medical, financial and psychosocial status were examined. Life satisfaction measures were compared with that of end stage renal disease patients and the overall United States population. Of the 1140 patients sent the written questionnaire, 347 (30.4%) returned the survey. Half the patients had been placed on home parenteral nutrition services because of short bowel syndrome. The mean length of time respondents had been receiving home parenteral nutrition services was 35 months, reporting approximately one hospitalization per year due to complications of their home parenteral nutrition. Blood infection with catheter as focus was most frequently reported as being responsible for hospitalization. The number of hospitalizations due to complications of home parenteral nutrition therapy was positively correlated with length of time on the program. Overall, respondents were satisfied with their home nutrition services, but were less satisfied with life as a whole when compared to the overall United States population and to end stage renal disease patients.

Practice patterns, attitudes and activities of Caucasian vs. Asian University of California-San Francisco PharmD graduates.

The results of a 1982 survey of graduates of the University of California at San Francisco (UCSF) doctor of pharmacy degree program were re-analyzed to explore whether cultural differences between Asian and Caucasian PharmD graduates affected professional practice patterns, attitudes and activities. Of the 732 respondents, 408 (56 percent) were Caucasians and 262 (36 percent) were Asians. Asian females had significantly fewer years of college education before entering pharmacy school and spend significantly fewer hours in the practice of pharmacy or related activities. Caucasians had a slightly higher grade point average than Asians. The mean score on the California State Board of Pharmacy Licensure Examination did not differ between the groups. For their first position following graduation, Asians predominated in operational positions, while Caucasians held clinical positions more frequently. Thirty-eight percent of Caucasians vs. 18 percent of Asians were taking or had completed postgraduate residency or fellowship training. An analysis of current jobs revealed that Asian males had the greatest increase in clinical positions when compared to the first position. Males of both ethnicities made the greatest gains in annual salary and in management positions compared to females.

P & T Committee interview: Promoting rational drug use.

In this exclusive Hospital Formulary interview, Thomas K. Hunt, MD, and Eric T. Herfindal, PharmD, chairman and secretary of the P & T Committee at the University of California San Francisco Medical Center, discuss how their Committee has evolved over the years. In a highly specialized medical center like UCSF, the P & T Committee has become the liaison between quality assurance and the medical staff. A diverse patient population necessitates a broad spectrum of agents, although restriction policies are common in order to minimize the spread of resistance or inappropriate use of drugs. Because of ongoing investigational drug research--including AIDS-related treatments--use of expensive, genetically-derived agents is often justified by the P & T Committee, in what Drs. Hunt and Herfindal describe as "million-dollar decisions."

Effect of postgraduate training on the careers of University of California Pharm.D. graduates.

Graduates of the University of California at San Francisco (UCSF) doctor of pharmacy degree program were surveyed to determine the effect of postgraduate pharmacy residency or fellowship training on the professional outcomes of these graduates. In 1982, a 39-item questionnaire was sent to 1061 UCSF School of Pharmacy alumni who had graduated in the years 1970 through 1981. The survey addressed several issues, including the graduates' general attitudes toward the profession of pharmacy, their practice patterns, and their professional activities. The response rate of the survey was 72%. Of the survey respondents, 30% had completed or were currently involved in a residency or fellowship program. Both postgraduates (PGs) and non-postgraduates (NPGs) indicated an overall satisfaction with life and the pharmacy profession as a whole. A greater fraction of PGs than NPGs worked in the hospital setting and held positions with varied job components (i.e., clinical, managerial, teaching, and operational activities). First-position salaries for both groups were the same regardless of postgraduate training status. Gender, rather than postgraduate status, was the major determinant of annual changes in salary, especially among men PGs. For managers, both men PGs and men NPGs had a greater change in mean salary per year of experience than their women counterparts. Of those graduates who did not hold management positions, men had a greater change in mean salary per year of experience than women. PGs had greater involvement in professional, educational, and publication activities than NPGs, and a smaller percentage of PGs than NPGs left the profession.(ABSTRACT TRUNCATED AT 250 WORDS)

Impact of decentralized pharmacokinetics consultation service.

The effects of pharmacokinetics consultation by a pharmacist on the quality of drug therapy were studied in a 500-bed teaching hospital. Data were collected retrospectively for three time periods: three months before, four months during, and three months after a period of intervention by a pharmacist with special responsibilities for pharmacokinetic monitoring of patients on a medical team. For the four-month intervention period, data were also collected for a parallel group of patients managed by another medical team that included pharmacy residents and students. Patients were included in the study if they had received either an aminoglycoside or a theophylline preparation. The preintervention, postintervention, and parallel groups were random samples of patients on the study ward, and the intervention group included all patients admitted to the pharmacist intervener's medical team who had received a drug covered by the study. Of serum drug concentration determinations (SDCDs) in the pharmacist intervention phase, 54% were appropriate, compared with 16% before intervention, 21% in the postintervention phase, and 46% in the patients of the other medical team. In the pharmacist intervention group, greater numbers of SDCDs were obtained appropriately and used appropriately in making therapeutic decisions, as evidenced by more subsequent measurements in the therapeutic range. Pharmacist intervention did not affect the number of adverse drug reactions or medical specialty consultations or the average length of stay. Decentralized pharmacokinetics services can have a positive effect on the quality of serum drug concentration determinations, dosage adjustments, and drug therapy.

Practice patterns, attitudes, and activities of University of California Pharm.D. graduates.

Graduates of the University of California at San Francisco (UCSF) Doctor of Pharmacy program from 1970 to 1981 were surveyed to determine their practice patterns, professional activities, and attitudes toward the profession of pharmacy. Of 1061 surveys mailed in September 1982, 752 (72%) were returned. A majority of respondents indicated that they would choose pharmacy as a profession again if starting over and that they would advise a friend to enter the profession. The private hospital setting was the practice site cited most frequently by respondents. Over one third of practicing pharmacists were actively enrolled in or had completed advanced pharmacy training. California was the practice location for 84% of respondents; only one third indicated that salary was very important or somewhat important in their decision to practice at their current location. A large percentage of respondents were involved in teaching, community service activities, and professional associations. Most entry-level UCSF Pharm.D. graduates are satisfied with their professional status and find opportunities for advancement.

Impact of clinical pharmacy services on prescribing on a cardiothoracic/vascular surgical unit.

A multi-faceted approach was used to study the impact of clinical pharmacy services on the cost of drug therapy on a cardiothoracic and vascular surgical service. Physician and nursing attitudes about the usefulness and likely effect of clinical pharmacist recommendations were also assessed. A cross-sectional design with a temporal factor was used to study physician prescribing of all pharmacologic classes, and particularly of antibiotics. Measurements were taken for nine months before the institution of clinical pharmacy services, 12 months during a clinical pharmacy service period, and for six months after the cessation of the services. A trend toward reduction in drug costs per patient day was observed on both services. This was observed for all pharmacologic classes, and when antibiotics were analyzed alone. The difference was significant when antibiotics were specifically analyzed on the vascular surgical service. The pharmacist's log and a survey of physicians' and nurses' attitudes toward clinical pharmacy services supported the above results.

Effect of clinical pharmacy services on prescribing on an orthopedic unit.

Prescribing patterns of physicians on a university-hospital orthopedic unit before, during, and after a clinical pharmacist's intervention were monitored and compared with patterns on a similar unit without clinical pharmacy services at another university hospital. The experimental and control groups consisted of 10% random samples of all patients on the study wards. Mean drug cost, number of doses, and number of courses of therapy for all drugs and for antibiotics were calculated. The data collection period consisted of 9 months (phase 1) before, 12 months (phase 2) during, and 6 months (phase 3) after clinical pharmacy services. Prescribing of postoperative prophylactic antibiotics was evaluated for compliance with guidelines of the experimental hospital's pharmacy and therapeutics committee. In the experimental group there was a consistent reduction from phase 1 to phase 2 in overall and antibiotic drug costs, number of doses, and number of courses of therapy per patient-day, but the differences were not significant. Length of stay decreased from phase 1 to phase 2, but the patterns were not significant over time or between experimental and control groups. For the experimental group, there was a significant reduction during phase 2 in the number of hours of antibiotic prophylaxis after removal of surgical drains, but prescribers' overall compliance with guidelines for postoperative antibiotic prophylaxis did not change significantly over time. In a subgroup receiving antibiotics, drug costs per patient-day at the experimental site were reduced from phase 1 to phase 2 for all drugs and for antibiotics. Of 1196 consultations, 76% were unsolicited; 83% of antibiotic-related problems were identified by the pharmacist.(ABSTRACT TRUNCATED AT 250 WORDS)