Association between late-life body mass index and dementia: The Kame Project.

OBJECTIVE: To examine the association between body mass index (BMI), waist circumference (WC), and waist-to-hip ratio (WHR) and risk of dementia and its subtypes in late life. METHODS: Participants were members of the Kame Project, a population-based prospective cohort study of 1,836 Japanese Americans living in King County, WA, who had a mean age of 71.8 years and were dementia-free at baseline (1992-1994), and were followed for incident dementia through 2001. Cox proportional hazards models were used to estimate the risk of dementia, Alzheimer disease (AD), and vascular dementia (VaD) controlling for demographic and lifestyle characteristics and vascular comorbidities as a function of baseline BMI, WC, and WHR and change in BMI over time. RESULTS: Higher baseline BMI was significantly associated with a reduced risk of AD (hazard ratio [HR] = 0.56, 95% confidence interval [CI] = 0.33-0.97) in the fully adjusted model. Slower rate of decline in BMI was associated with a reduced risk of dementia (HR = 0.37, 95% CI = 0.14-0.98), with the association stronger for those who were overweight or obese (HR = 0.18, 95% CI = 0.05-0.58) compared to normal or underweight (HR = 1.00, 95% CI = 0.18-5.66) at baseline. CONCLUSION: Higher baseline body mass index (BMI) and slower declining BMI in late life are associated with a reduced risk of dementia, suggesting that low BMI or a faster decline in BMI in late life may be preclinical indicators of an underlying dementing illness, especially for those who were initially overweight or obese.

Pharmacy staff training and development: upside-down thinking in a changing profession.

We suggest that the most fundamental change in staff development that must occur is recognition of the need for a professional belief system as the basis for any pharmaceutical care activity. Values derived from fundamental moral ideals and professional beliefs foster the development of attitudes and behaviors. It would be wrong to suggest or imply that such a change need only occur in postbaccalaureate training. The development of personal and professional value systems in existing primary professional training programs is inadequate--we do not yet do enough to develop people before they enter practice. Nevertheless, to say that this failure of the professional education system precludes us from taking action within professional departments is unwise. The primary skills that must be developed during the next decade involve the ability of the practitioner to competently make informed, patient-specific decisions necessary for effective pharmaceutical care. Such decisions are made not only on the basis of a practitioner's knowledge but on the basis of his or her beliefs and values as well. The practitioner also must be willing to assume responsibility for the consequences of those decisions. The pharmacist who professes to deliver pharmaceutical care can no longer be shielded by assigning to the physician the ultimate responsibility for the patient's drug-therapy outcomes. Facilitating the development of a value system and attitude that enhance the pharmacist's ability to make such decisions must be a principal focus of staff training and development in the coming years.(ABSTRACT TRUNCATED AT 250 WORDS)

Ethical issues associated with managed care pharmacy services.

The authors' purpose in raising these issues and questions is not to provide answers for the profession. We recognize that answers must be derived from a process that includes input from many individuals, and from many sectors of the profession. We also recognize that the pharmacist practicing today realizes that the health care system is changing. We believe that the code of ethics supporting our profession must be revised to reflect these changes to provide more meaningful guidance for pharmacists confronting difficult contemporary issues and dilemmas. We have tried to show that pharmacists working in the HMO setting may face unique problems that must be considered by a revised code of ethics. We are pleased that APhA has begun this process of revision.

Financial impact of home health care on the hospital.

A method for analyzing the financial impact of new home health-care (HHC) programs on the hospital is presented. Clinical service objectives and long-term goals for new programs must match patient needs with institutional opportunities and constraints. Planning and evaluating new HHC programs require an accurate analysis of the financial impact of the proposed program on the hospital. A method for financial program analysis is presented through three different hypothetical scenarios based on realistic situations of hospitals considering HHC alternatives. Marginal analysis is presented as a microeconomic tool, and the calculation of marginal cost from a linear total cost function is described. Pro forma spread sheets of revenue and expense are used to assess three different HHC program alternatives--an independent HHC agency, a hospital-based agency, and a joint venture between a vendor and a hospital. Net present-value calculations are explained and applied to one case. It is important to use realistic assumptions in estimating the financial performance of HHC programs.

Objectives of an effective inventory control system.

Quantitative decision-making processes are examined as they relate to hospital pharmacy inventory control. The objective of an inventory-control system is to make inventory decisions that minimize the total cost of inventory, which is distinctly different from minimizing inventory. It is often more expensive to run out of an item (and thus be forced to obtain it through more expensive channels) than simply to keep more units in stock. Several models have been proposed in the literature for minimizing the total cost of inventory through the use of an economic order quantity, which attempts to balance the carrying costs of inventory with the cost of running out of an item. Most pharmacy inventory decisions involve replenishment--how much to order, when to decide to order, and when to place the order. There are three costs associated with pharmacy inventory: (1) carrying costs, (2) shortage costs, and (3) replenishment costs. Many of the proposed models (which are discussed in detail in the article) make certain assumptions that do not hold in the realm of hospital pharmacy. For instance, the "costs" associated with running out of a drug product used in critical care might well involve increased morbidity and mortality, clearly an unacceptable situation. However, the basic tenets of these inventory-control systems should be examined by hospital pharmacy managers and applied when appropriate. The availability of microcomputers and relatively powerful spreadsheets will increase the utility of complex models of inventory control that are too complicated for manual calculations.(ABSTRACT TRUNCATED AT 250 WORDS)