Commercial Pharmacy Research Articles

Methods for county-level estimation of pre-exposure prophylaxis coverage and application to the U.S. Ending the HIV Epidemic jurisdictions

PurposePre-exposure prophylaxis (PrEP) is a pillar of the US Department of Health and Human Services “Ending the HIV Epidemic” (EHE) initiative in 50 EHE jurisdictions (48 U.S. counties and two U.S. cities) and seven U.S. states with high numbers of HIV diagnoses rates in rural areas. Current data systems do not provide data on PrEP uptake in counties or cities. MethodsWe report on PrEP users at the county level. Data from a large, commercial pharmacy database were used; we applied the U.S. Census Bureau's method to allocate PrEP users within a ZIP3 into counties and validated the results. We report counts and rates of PrEP users in 2018 for all EHE jurisdictions. We used joinpoint regression to model the estimated annual percent change in PrEP use for each jurisdiction and state. Results93,156 people in the 50 EHE jurisdictions used PrEP in 2018; 94% were men and 39% were aged 25–34 years. There was more than an 80-fold difference in the range of rates of PrEP use per 100,000 population among the EHE jurisdictions (range: 8–644 per 100,000 population; median 93 per 100,000 population). PrEP use increased from 2012 to 2018 in all EHE counties and states. At current rates of growth of PrEP use, 94% of EHE counties and jurisdictions will reach their National HIV/AIDS Strategy goals of a 500% increase in PrEP use in 2020. EHE states had less variation in rates of PrEP use (range: 29–51/100,000 population; median 32/100,000 population). ConclusionsAt the outset of a major U.S. government program to reduce HIV infections, rates of PrEP use are highly variable among the 50 EHE jurisdictions. Data from commercial prescription databases will be a useful public resource to understand progress in promoting use of PrEP as part of the EHE initiative and evaluating progress in PrEP use across health jurisdictions.

The Total Direct Cost of Healthcare in the United States in Patients with Sickle Cell Disease: A Propensity Score Matched Analysis

Introduction: Sickle cell disease (SCD) is an inherited blood disorder with significant healthcare resource utilization in the United States (US). The clinical management throughout the course of the disease is variable. Children born with SCD in the US receive routine comprehensive care that significantly reduces their morbidity and mortality. Upon transition to adulthood, there are marked increases in disease-related complications and morbidity. The extent to which disease management costs vary by age and overall lifetime cost of treatment are unknown. The aim of this study is to estimate the total direct healthcare cost among patients with SCD in the US across consecutive age ranges. Methods: We estimated direct costs of chronic management for SCD through a retrospective database analysis of Optum's de-identified Clinformatics® Data Mart Database (CDM) commercial insurance medical and pharmacy claims from January 1, 2007 to December 31, 2017. CDM provides information on 15 to 18 million annual insured lives and roughly 57 million unique lives over our study period (2007-2017). The population spans 50 states and is similar to the US distribution with respect to sex, age, and geography. We identified patients using ICD-9-CM (282.4x or 282.6x) and ICD-10-CM (D57.x sans D57.3x) diagnosis codes. Patients were required to have at least one inpatient (IP) claim or three or more outpatient (OP) claims (spaced at least 30 days apart) with a diagnosis of SCD and minimum of one year of continuous enrollment in both medical and prescription drug coverage. Each patient's index date was designated the date of their first SCD-related claim for patients with SCD, or their first date of eligibility for patients without SCD (controls). We matched patients with SCD to controls using 1:1 propensity score matching without replacement with a greedy nearest neighbor algorithm. Propensity scores were generated using probit regression on covariates gender, state, plan type, year of birth, and index year. Total direct costs of healthcare including IP, OP, professional (PF), ancillary (AN), and pharmacy (RX) services were calculated first year post-index (Y1), second year post-index (Y2), third year post-index (Y3), and overall (annualized) post-index. We calculated annualized costs by aggregating all costs after index and dividing by the remaining number of years the patient was eligible for coverage. Average incremental costs (AIC) are defined as the mean difference in costs between patients with SCD and respective controls. We report AIC by decade of age on the patient's index date, inflated to 2018 US dollars. All analyses were performed in SAS 9.4 (SAS Institute, Raleigh, NC) and Stata 16.0 (StataCorp, College Station, TX). This study was approved by the University of Southern California's University Park Institutional Review Board (UPIRB). Results: We identified 10,447 patients with SCD along with 10,447 unique matched controls from 2007 to 2017. Average total costs (sum of IP, OP, PF, AN, and RX costs) for patients with SCD were greater at all age categories, relative to controls. Annualized AIC, i.e. costs attributable to management of SCD, ranged from $18,859 (SD = 44,716) for ages 0-9 to $43,586 (SD = 109,735) for ages 20-29 (Table 1). First-year AIC were consistently greater than second and third-year AIC across all age groups (Figure 1). For patients with SCD, AIC were greatest for patients in the 20-29 years band across all specifications. Details on AIC of SCD management across all consecutive age ranges are available in Table 1. Conclusions: The cost of disease management for patients with SCD in the US is substantial. We observe a rise in SCD-specific costs from childhood to early adulthood. This may reflect the higher risk of disease-associated complications and mortality seen during this period. Additionally, AIC first year after initial SCD-related claim are consistently higher compared to AIC in years two and three. This finding may be attributable to an increased utilization of healthcare services from previously underinsured patients with SCD. Future work should involve simulating estimated lifetime total direct cost of healthcare attributable to management of SCD for patients in the US. Disclosures No relevant conflicts of interest to declare.

Descriptive Analysis of Long- and Intermediate-Acting Insulin and Key Safety Outcomes in Adults with Type 2 Diabetes Mellitus.

As new biosimilar and follow-on insulins enter the market, more data are needed on safety, effectiveness, and patterns of use for these products to inform prescriber and patient decision-making regarding treatment. Additionally, data are needed regarding real-world patterns of use to inform future studies comparing the safety and effectiveness of bio-similars to already approved agents for diabetes treatment. To analyze the medication use patterns, adverse events, and availability of glycated hemoglobin (A1c) values for adult patients with type 2 diabetes mellitus (T2DM) who use long-acting insulin (LAI) or neutral protamine Hagedorn (NPH), an intermediate-acting insulin. We used the Biologics and Biosimilars Collective Intelligence Consortium's (BBCIC) distributed research network (DRN) for this descriptive analysis. The analysis time frame was January 1, 2011, to September 30, 2015, and included patients continuously insured for at least 183 days before the first date of a filled prescription for LAI or NPH insulin alone or with rapid- or short-acting insulin or sulfonylureas, whether newly starting insulin or switching to a different product. Insulin exposure episodes were the unit of analysis, and patients were classified in cohorts according to treatment. We followed patients until end of health plan enrollment or the end of the study period. We used occurrence of a study outcome, switch to another medication regimen, discontinuation of the current medication, or study end date to mark the end of an insulin episode. We describe demographics and availability of A1c values for analysis. Study outcomes included severe hypoglycemic events and major adverse cardiac events (MACE). We identified 103,951 patients with T2DM from a database of 39.1 million patients with commercial or Medicare Advantage pharmacy and medical benefits, who contributed 279,533 unique insulin exposure episodes. Most episodes (89%) included patients using LAI, and 52% of patients contributed data to 2 or more exposure cohorts. Insulin episodes lasted an average of 3.5 months, and patients had an average follow-up of 8.6 months. The unadjusted rate of severe hypoglycemic events requiring medical attention was 96.9 per 10,000 patient-years at risk (10kPYR). The unadjusted incident MACE rate was 676.9 events per 10kPYR. 38,330 T2DM patients in the BBCIC DRN had a baseline A1c available, and of those, less than 50% had a follow-up A1c result. Among patients with T2DM, our observed insulin patterns of use and rates of severe hypoglycemic outcomes and MACE are consistent with other studies. We noted a paucity of A1c results available, which implies that additional data sources may be needed to augment the BBCIC DRN. This study was coordinated and funded by the Biologics and Biosimilars Collective Intelligence Consortium (BBCIC) and represents the independent findings of the BBCIC Insulins Principal Investigator and the BBCIC Insulins Research Team. Lockhart is employed by the BBCIC and the Academy of Managed Care Pharmacy (AMCP). Eichelberger was employed by the BBCIC and AMCP at the time of this study. McMahill-Walraven is employed by Aetna, a CVS Health business. Panozzo, Marshall, and Brown are employed by Harvard Pilgrim Healthcare Institute. Aetna was reimbursed for data and analytic support from Harvard Pilgrim Healthcare Institute and the Reagan Udall Foundation for the U.S. Food and Drug Administration. Aetna receives external funding through research grants and subcontracts with Harvard Pilgrim Healthcare Institute, which are funded by the FDA, NIH, PCORI, BBCIC, Pfizer, and GSK; the Reagan-Udall Foundation for IMEDS; and PCORI for the ADAPTABLE Study. This work was previously presented as a poster at AMCP Nexus 2018; October 22-25, 2018; in Orlando, FL.

Opioid Prescribing to Adolescents in the United States From 2005 to 2016.

This study assessed trends in days' supply for opioid prescriptions filled by adolescents with commercial insurance and Medicaid. IBM MarketScan commercial and Medicaid pharmacy claims data were used to measure days' supply among adolescents (2005-2016) and to determine whether there were differences between patients with commercial insurance or Medicaid coverage. The 2-3 days' supply decreased from 50.5% (2005) to 36.7% of fills (2016), while 4-5 days' supply increased from 30.2% to 37.7%. Fills of 6-7 and 8-15 days increased slightly. Fills of over 30 days remained near 0.0%, and one-day fills remained at 1.0-2.0% until 2016, when they increased to 3.6% Conclusions: For adolescents, fills of prescription opioids generally exceeded three days. Efforts to reduce opioid prescribing through guidelines, prescription drug monitoring programs, and limits on days' supply do not appear to have affected prescribing for adolescents as much as desired.

Predictors of latent tuberculosis infection treatment completion in the US private sector: an analysis of administrative claims data

BackgroundFactors that affect latent tuberculosis infection (LTBI) treatment completion in the US have not been well studied beyond public health settings. This gap was highlighted by recent health insurance-related regulatory changes that are likely to increase LTBI treatment by private sector healthcare providers. We analyzed LTBI treatment completion in the private healthcare setting to facilitate planning around this important opportunity for tuberculosis (TB) control in the US.MethodsWe analyzed a national sample of commercial insurance medical and pharmacy claims data for people ages 0 to 64 years who initiated daily dose isoniazid treatment between July 2011 and March 2014 and who had complete data. All individuals resided in the US. Factors associated with treatment completion were examined using multivariable generalized ordered logit models and bivariate Kruskal-Wallis tests or Spearman correlations.ResultsWe identified 1072 individuals with complete data who initiated isoniazid LTBI treatment. Treatment completion was significantly associated with less restrictive health insurance, age < 15 years, patient location, use of interferon-gamma release assays, non-poverty, HIV diagnosis, immunosuppressive drug therapy, and higher cumulative counts of clinical risk factors.ConclusionsPrivate sector healthcare claims data provide insights into LTBI treatment completion patterns and patient/provider behaviors. Such information is critical to understanding the opportunities and limitations of private healthcare in the US to support treatment completion as this sector’s role in protecting against and eliminating TB grows.

The impact of ribavirin on real-world adherence rates in hepatitis C patients treated with sofosbuvir plus simeprevir.

BackgroundCombination therapy with sofosbuvir (SOF) and simeprevir (SIM) is used to treat patients with hepatitis C virus infection. It is currently unknown whether adding ribavirin (RBV) to SOF + SIM, which raises the pill count from two up to eight pills a day, impacts adherence. The aim of this study is to examine the impact of pill count on real-world adherence rates in patients treated with SOF + SIM with and without RBV.MethodsThis retrospective study assessed composite adherence to SOF and SIM over 12 weeks of treatment for two cohorts of hepatitis C patients: one initiating SOF + SIM therapy, and the other initiating SOF + SIM + RBV therapy. Analyses were conducted using MarketScan® and Optum US commercial pharmacy claims and enrollment data. Adherence was adjusted by treatment regimen, age, sex, co-pay, presence/absence of cirrhosis, treatment history, and Charlson Comorbidity Index.ResultsThere was a significant difference in composite unadjusted and adjusted adherence rates for SOF and SIM for the SOF + SIM vs SOF + SIM + RBV cohorts based on MarketScan data (unadjusted, 92.6% and 89.7%, respectively; P=0.0423; adjusted, 92.2% and 88.7%, respectively; P=0.0176), but not based on Optum data (unadjusted, 94.8% and 95.6%, respectively; P=0.5618; adjusted, 94.8% and 95.1%, respectively; P=0.8589). In the MarketScan and Optum databases, there were no statistical differences in unadjusted and adjusted adherence rates for SOF. Unadjusted and adjusted adherence rates for SIM were mixed, as they were for composite adherence.ConclusionThe impact of the addition of RBV to SOF + SIM therapy was mixed. The impact of RBV on SOF adherence was not significant in either database.

Wish-fulfilling jewel pills: Tibetan medicines from exclusivity to ubiquity

Despite the recent growth of social science literature concerning the traditional medicine industry in Asia, insights into the contemporary dynamics of so-called ‘classical formulae’ remain relatively scant, as do studies of small-scale, less capitally intensive and technologically advanced modes of production. This paper seeks to address these gaps by considering a single Sowa Rigpa (Tibetan medicine) formula known as Samphel Norbu, or ‘wish-fulfilling jewel’, which appears in numerous texts and is today among the most popular Tibetan medicines in the world. Drawing primarily upon long-term fieldwork in Himalayan India, the paper follows Samphel Norbu's rise from exclusivity to popularity and examines the ways it has been transformed in the process, both materially and in its economic, social and clinical significance. The paper shows how Samphel Norbu acts as a marker of inequality between different groups of healers, and examines the role the medicine played in the development of commercial pharmacy and the proliferation of complex medicines. Tracing out wide variations in the medicine's formulation, composition, mode of production and pattern of circulation places the issue of multiplicity at the centre of analysis, and leads to a questioning of the assumptions that underpin the category ‘classical formula’. The paper reflects upon the repositioning of such formulae within emergent configurations of knowledge, power, industry and market, and on their transformations and transformative effects both over time and in the present moment.

Piloting an HIV self-test kit voucher program to raise serostatus awareness of high-risk African Americans, Los Angeles.

BackgroundUp to half of all new HIV cases in Los Angeles may be caused by the 20-30% of men who have sex with men (MSM) with unrecognized HIV infection. Racial/ethnic minority MSM are at particularly high risk for being sero-unaware and due to stigma and poor healthcare access might benefit from novel private, self-testing methods, such as the recently FDA-approved OraQuick® In-Home HIV Test.MethodsFrom July-November 2013, we undertook a pilot study to examine the feasibility of a voucher program for free OraQuick® tests targeting African American MSM in Los Angeles. We determined feasibility based on: (1) the establishment of a voucher redemption and third-party payment system, (2) the willingness of community-based organizations (CBOs) to disseminate vouchers, and (3) the collection of user demographics, test and linkage-to-care results with an anonymous telephone survey.ResultsWe partnered with Walgreens® to create a voucher and third-party reimbursement system for free OraQuick® tests. Voucher distribution was divided into two periods. In total, 641 vouchers were supplied to CBOs: 274 (42.7%) went to clients and of those 53 (19.3%) were redeemed. Fifty (18.2%) of the 274 clients were surveyed: 44 (88%) were African American, 39 (78%) reported being likely to repeat voucher use, 44 (88%) reported reviewing pre-test information, and 37 (74%) the post-test information. Three (6%) of 50 survey respondents reported newly testing HIV-positive of whom all (100%) reported seeking medical care. Two withheld their results, both of whom also sought medical care.ConclusionsDeveloping and partnering with a commercial pharmacy to institute a voucher system to facilitate HIV self-testing with linkage-to-care was feasible. Our findings suggest the voucher program was associated with increasing the identification of new cases of HIV infection with high rates of linkage to care. Expanded research and evaluation of voucher programs for HIV self-test kits among high-risk groups is warranted.

Opioid Use Among Adolescent Patients Treated for Headache

To determine the pervasiveness of opioid prescribing for adolescents with headache and patient and provider characteristics associated with likelihood of opioid prescribing. This observational cohort analysis used commercial medical and pharmacy claims between January 1, 2007 and December 31, 2008. Included were adolescents (13-17 years of age) with newly diagnosed headache, ≥2 distinct claims for headache, and ≥12 months health plan eligibility preindex and postindex. Adolescents with a trauma diagnosis at any point were excluded. The primary outcome was current practice patterns, measured by a number of opioid claims, a percentage of patients prescribed opioids, a number of opioid prescriptions per year, a length of opioid therapy, and a frequency of specific comorbidities. A secondary outcome characterized providers and practice settings, comparing patients who received opioids with those who did not. Of 8,373 adolescents with headache, 46% (3,859 patients) received an opioid prescription. Nearly half (48%) received one opioid prescription during follow-up; 29% received ≥3 opioid prescriptions. Of those with opioid prescriptions, 25% (977 patients) had a migraine diagnosis at index date. Among adolescents who received opioids, 28% (1,076 adolescents) had an emergency department (ED) visit for headache during follow-up versus 14% (608 adolescents) who did not receive opioids (p < .01). ED visits with a headache diagnosis during follow-up were strongly correlated with opioid use after adjusting for other covariates (odds ratio, 2.02; 95% confidence interval, 1.79-2.29). Despite the treatment guidelines recommending against their use, a large proportion of adolescents with headache were prescribed opioids. ED visits were strongly correlated with opioid prescriptions.

Compounding Pharmacies: A Viable Option, or Merely a Liability?

You have recently been appointed to be the medical director of an ambulatory surgical center. This center focuses on interventional spine procedures and is used by several independent physician practices in the community. The manager of the center approaches you regarding medication options at the center. Several physicians in the group are requesting that she reorder preservative-free betamethasone phosphate from a compounding pharmacy. They believe strongly that this corticosteroid formulation has the distinct advantage of containing neither particulates nor preservative but is not available from a commercial pharmacy. In contrast, the commercially available form of betamethasone (Celestone Soluspan [Schering Corp, Kenilworth, NJ]), both contains a preservative and is a particulate corticosteroid due to the inclusion of betamethasone acetate in its formulation. The manager of the center is aware of the recent meningitis outbreak and is concerned that allowing any medications from compounding pharmacies is an unacceptable risk to patients. She also believes that using a compounding pharmacy in this setting may be a medicolegal liability to the surgical center. David O’Brien, MD, will argue that physicians should have the ability to use compounding pharmacies and Isaac Cohen, MD, will argue that compounding pharmacies should not be used. Please note the views expressed in this article are for educational purposes only and do not constitute a personal endorsement or necessarily reflect the current practice patterns of the discussants. They also are not intended to establish the standard of care.

Community pharmacists’ occupational satisfaction and stress: A profession in jeopardy?

ObjectivesTo quantify and model drivers of community pharmacists’ self-reported levels of occupational satisfaction and stress and to identify key segments for possible intervention by the profession. DesignDescriptive nonexperimental study. SettingUnited States during January to February 2012. Participants303 independent and community chain pharmacists. InterventionOnline survey instrument of previously validated occupational stress and satisfaction attribute batteries. ResultsParticipants reported a high level of dissatisfaction with current employment, with more than 50% stating that they were considering quitting their jobs. Dissatisfaction was higher among those with a doctor of pharmacy degree and those employed in community chains. Occupational stress and satisfaction were highly correlated with the intention to search for a new position. Approximately 20% of respondents felt that stress from their employment adversely affected their mental health and well-being, physical health, quality of the work, or relationships with family and friends. ConclusionSubstantive levels of occupational dissatisfaction and stress exist among pharmacists currently in community practice. These negative attributes are associated with a damaging promotion of community practice—a marker of a negative trajectory in sustaining this practice environment. The results of this study have implications for the health care industry, commercial pharmacy vendors, independent pharmacies, the profession, and academic training institutions as they prepare the pharmacy workforce of the future for potentially dissatisfying and stressful work environments.

The Effect of a Specialized Case Management Program On Factor Replacement Use On Patients with Bleeding Disorders

AbstractAbstract 4257Patients with Hemophilia A and B and Von Willebrand Disease have benefitted from improvements in the management of their disease over the past generation, both in terms of quality of life and life expectancy. Since these are chronic conditions they require ongoing management and treatment. This often results in a significant cost. The major contributor to this is the cost of factor replacement, which can be magnified if not handled in the most efficient manner. This pressure exists across the spectrum of medical coverage in the United States from commercial third party payors to Medicaid and even for the uninsured. In response to pressure to contain costs there is an increasing variety of coverage and cost-sharing strategies which may have an unintended effects on the care these patients receive. In response, we report on the financial impact of an intervention by specially trained case managers under close clinical guidance on patients with these diagnoses. Methods:A team consisting of a medical director, nurse case managers and an outside advisor with expertise in the field of bleeding disorders evaluated every member of the insurance plan identified with the diagnosis of Hemophilia A, Hemophilia B or Von Willebrand's disease. The evaluation consisted of an assessment of the individual's clinical status related to the diagnosis, complications and co-morbidities. Information on where care was obtained, how often follow up occurred and the specific treatment regimen was collected. Specific attention was paid to the type of replacement product used, the amount and the treatment regimen. The source of replacement therapy was noted (i.e., insurer associated pharmacy, 340B program or commercial pharmacy) and a comparison of costs was performed. Patients were then educated on the differences and given a choice as to where their future pharmaceutical needs would be met. Ultilization was followed for a year and the amount of saving was calculated. Results:The result shows the achievement of significant savings through this program, as shown in the table below. These savings were achieved without changing the regimen or any aspect of the treatment plan initiated by the treating team, but by simply offering a more financially beneficial source to supply replacement therapy. In the vast majority of these cases that choice involved using a 340B program when available. The saving tended to be higher among those receiving prophylaxis as those regimens used the most factor replacement.Results for the year 2011Total evaluable cases who received the intervention: 119ConditionsTotal casesOn Demand CasesProphylaxis CasesHemophilia A704327Hemophilia B33258VWD16160Total1198435Number of cases with savings and total amount of savingsSavingsHemophilia AProphylaxis Cases14 of 43 (33%)$618,387On-Demand Cases11 of 27 (41%)$152,557Total25 of 70 (35%)$770,994Hemophilia BProphylaxis Cases6 of 8 (75%)$813,276*On-Demand Cases9 of 25 (36%)$179,297Total15 of 33 (45%)$992,573VWDTotal5 of 16 (31%)$29,391Total Savings$1,792,958 Conclusion:With an increase in cost sharing strategies, which will require increased out of pocket expenditures on the part of patients with even the best insurance coverage there is a need to be more cognizant of how health care dollars are spent. This is especially true for those with chronic conditions that are expensive to treat, with these bleeding disorders being a prime example. The 340B programs available throughout the country offer a substantial discount that appears to be sub optimally utilized. Furthermore these programs are often associated with large academic centers that are able to offer these patients the most advanced treatments available.In our project we have been able to show savings in excess of $1.5 million using a relatively simple intervention. It is worth noting that there were a significant number of members who chose not to make any changes as the choice of participation were solely voluntary. Furthermore there was no attempt to change to a less expensive alternative. The implication is that this represents a simple intervention that can be made in other setting including other commercial plans and national programs and can show a large financial impact for these patients. In addition, this program allows ongoing reevaluation of a patient to respond to changes in an individual's relevant needs. Disclosures:Bonagura:Aetna Insurance: Employment. Decristofano:Aetna Insurance: Employment. Faulds:Aetna Insurance: Employment. Rich:Aetna Insurance: Employment. Schiavone-Grosser:Aetna Insurance: Employment. Deniz:Aetna Insurance: Employment. Aledort:Aetna Insurance: Advisor Other.

Integrating historical clinical and financial data for pharmacological research

BackgroundRetrospective research requires longitudinal data, and repositories derived from electronic health records (EHR) can be sources of such data. With Health Information Technology for Economic and Clinical Health (HITECH) Act meaningful use provisions, many institutions are expected to adopt EHRs, but may be left with large amounts of financial and historical clinical data, which can differ significantly from data obtained from newer systems, due to lack or inconsistent use of controlled medical terminologies (CMT) in older systems. We examined different approaches for semantic enrichment of financial data with CMT, and integration of clinical data from disparate historical and current sources for research.MethodsSnapshots of financial data from 1999, 2004 and 2009 were mapped automatically to the current inpatient pharmacy catalog, and enriched with RxNorm. Administrative metadata from financial and dispensing systems, RxNorm and two commercial pharmacy vocabularies were used to integrate data from current and historical inpatient pharmacy modules, and the outpatient EHR. Data integration approaches were compared using percentages of automated matches, and effects on cohort size of a retrospective study.ResultsDuring 1999-2009, 71.52%-90.08% of items in use from the financial catalog were enriched using RxNorm; 64.95%-70.37% of items in use from the historical inpatient system were integrated using RxNorm, 85.96%-91.67% using a commercial vocabulary, 87.19%-94.23% using financial metadata, and 77.20%-94.68% using dispensing metadata. During 1999-2009, 48.01%-30.72% of items in use from the outpatient catalog were integrated using RxNorm, and 79.27%-48.60% using a commercial vocabulary. In a cohort of 16304 inpatients obtained from clinical systems, 4172 (25.58%) were found exclusively through integration of historical clinical data, while 15978 (98%) could be identified using semantically enriched financial data.ConclusionsData integration using metadata from financial/dispensing systems and pharmacy vocabularies were comparable. Given the current state of EHR adoption, semantic enrichment of financial data and integration of historical clinical data would allow the repurposing of these data for research. With the push for HITECH meaningful use, institutions that are transitioning to newer EHRs will be able to use their older financial and clinical data for research using these methods.

Errors associated with outpatient computerized prescribing systems

To report the frequency, types, and causes of errors associated with outpatient computer-generated prescriptions, and to develop a framework to classify these errors to determine which strategies have greatest potential for preventing them. This is a retrospective cohort study of 3850 computer-generated prescriptions received by a commercial outpatient pharmacy chain across three states over 4 weeks in 2008. A clinician panel reviewed the prescriptions using a previously described method to identify and classify medication errors. Primary outcomes were the incidence of medication errors; potential adverse drug events, defined as errors with potential for harm; and rate of prescribing errors by error type and by prescribing system. Of 3850 prescriptions, 452 (11.7%) contained 466 total errors, of which 163 (35.0%) were considered potential adverse drug events. Error rates varied by computerized prescribing system, from 5.1% to 37.5%. The most common error was omitted information (60.7% of all errors). About one in 10 computer-generated prescriptions included at least one error, of which a third had potential for harm. This is consistent with the literature on manual handwritten prescription error rates. The number, type, and severity of errors varied by computerized prescribing system, suggesting that some systems may be better at preventing errors than others. Implementing a computerized prescribing system without comprehensive functionality and processes in place to ensure meaningful system use does not decrease medication errors. The authors offer targeted recommendations on improving computerized prescribing systems to prevent errors.

Consumo de medicamentos entre adultos na área de abrangência de uma Unidade de Saúde da Família

There are few studies about the consumption of medication by adults in Brazil. Therefore, the purpose of this research was to identify the profile of medication consumption and associated factors among adults aged 29 to 59 years old. This is a cross-sectional study. The sample included 374 individuals from the area of a family health unit in the city of Ponta Grossa, State of Paraná. The interviews were conducted from December 2006 to January 2007, with a 7-day recall. The medications were classified according to the Anatomical Therapeutic Chemical Classification. Qui-square test and logistic regression were used for statistical analysis. The prevalence of medication consumption was 67.1%. The use varied from 1 to 17 drugs. Analgesics were the therapeutic class most consumed. After multivariate analysis, the variables which remained significantly associated to use were: gender, self-perception of health, presence of chronic diseases, and access to a health plan. Commercial pharmacy was the main place for obtaining medicines (63.6%). The prevalence of medication consumption was similar to that found in national and international studies. The findings in this research may be a guide for the actions of family health teams.

FARMÁCIA DOMICILIAR: UMA CAIXA DE SURPRESAS.

O intuito do estudo é fornecer à comunidade orientação e informação sobre cada medicamento que possuem em casa e indiretamente demonstrar aos clientes de farmácia comercial o quão importante é utilizar-se dos conhecimentos do farmacêutico que realiza a atenção farmacêutica, um serviço ainda pouco conhecido. Para a realização da pesquisa, realizou-se o convite aos clientes em uma farmácia comercial do município de Cascavel-PR, esclarecendo-os sobre o objetivo do mesmo, para os quinze primeiros aceites foi explicado o termo de consentimento livre e esclarecido e havendo concordância, marcou-se um horário para o atendimento que foi realizado no escritório da farmácia. A análise baseou-se na “fase da sacola de medicamentos” do método Dadér de acompanhamento farmacoterapêutico. No modo geral, a comunidade apresentou certa desenvoltura no conhecimento da sua caixinha de medicamentos domiciliares e interesse pelo serviço diferenciado proposto.

Pharmacotherapy Interventions Undertaken by Pharmacists in the Fleetwood Phase III Study: the Role of Process Control

The Fleetwood Model incorporates prospective review, direct communication with the prescriber, and formalized pharmacotherapy planning in patients at highest risk for medication-related problems. To describe the intervention activities performed by consultant pharmacists and dispensing pharmacists in the context of the Fleetwood Phase III Study. We report on a total of 4272 residents living in 12 nursing homes included in the intervention arm of the demonstration project. The intervention period was January through December 2004. Using pharmacotherapy planning software with a Web-based interface, daily interchange of information from the commercial pharmacy software, as well as laptop-based software for use in the nursing homes, pharmacists documented the reason for the intervention, the level of service, and the extent to which the recommendations were accepted. There were 2118 Fleetwood interventions performed on 4272 residents (intervention rate: 9.48/100 resident months), with 81% of interventions performed by consultant pharmacists. The top 5 reasons for Fleetwood interventions by dispensing pharmacists were: missing information/clarification needed (19.8%), drug-age precautions (14.4%), excessive duration alert (9.5%), suboptimal regimen (8.7%), and laboratory test needed (7.3%). The top 5 reasons for involvement of the consultant pharmacists were: laboratory test needed (13.1%), missing information/clarification needed (13%), unnecessary drug (10.3%), product selection opportunity (10.3%), and excessive duration alert (9.1%). Extending the federally mandated medication review process in nursing homes to incorporate elements of the Fleetwood Model is possible. The recommendation acceptance rates for pharmacist interventions are high.

Experiments, models, paper tools: cultures of organic chemistry in the nineteenth century

Preface Introduction 1. The Semiotics of Berzelian Chemical Formulas The Various Meanings of Berzelian Formulas Image and Language: The Syntax of Berzelian Formulas 2. Two Cultures of Organic Chemistry in the Nineteenth Century: A Structural Comparison The Area of Research Objects in Early Nineteenth-Century Plant and Animal Chemistry Plant and Animal Substances: A Cross between Natural History and Chemistry The Classification of Plant and Animal Substances Nature and Art in the Experimental Practice of Plant and Animal Chemistry The Experimental Culture of Organic Chemistry after 1840 The Two Forms of Organic Chemistry Compared 3. Experiments on the Periphery of Plant Chemistry Ether Production and Commercial Pharmacy Interpretive Models of the Formation of Ordinary Ether around 1800 Quantitative Approaches in the Study of Organic Reactions Simplified Quantitative Experiments The Manufacture of an Artificial Oil in the Chemical Laboratory New Attempts to Balance the Masses of Reacting Substances The Overthrow of the Accepted Interpretive Model of the Formation of Ordinary Ether 4. Paper Tools for the Construction of Interpretive Models of Chemical Reactions The Historical Problem Modeling Separate Reaction Pathways The Performative Function of Berzelian Formulas 5. Paper Tools for the Classification of Organic Substances The Structure and Function of Dumas and Boullay's Table Experimentation and the Construction of Formula Models for the of Bicarbonated Hydrogen The Enlargement of Substance Classes by the Construction of Further Formula Models Manipulations of Formulas and Their Significance Reception of the New Classification among European Chemists 6. Paper Tools for Modeling the Constitution of Organic Compounds The Shared Conceptual Preconditions for the Models of Constitution Models of Constitution Prior to 1833 The Controversy 7. The Dialectic of Tools and Goals A Performative Account of Conceptual Development The Creation of Mutual Adjustments and Its Reflection in the New Mode of Justification 8. The Historical Transformation Process Model Objects and Unintended Paradigmatic Achievements The Structural Transformation 9. Paper Tools Filling in the Gaps of Inscription Devices Chains of Inscriptions and Paper Tools Notes Literature Cited Index

The 'Dutch drugstore' as an attempt to reshape pharmaceutical practice: the conflict between ethical and commercial pharmacy in Dutch cultures of medicines.

The 'Dutch drugstore' as an attempt to reshape pharmaceutical practice: the conflict between ethical and commercial pharmacy in Dutch cultures of medicines.

Assessment of adherence with medications in human immunodeficiency virus-infected children.

The purpose of this study was to determine the reliability of screening for medication adherence in HIV-infected children. The results suggest that caregivers who are unable to describe the medication regimen or who are nonadherent with appointments are unlikely to adhere to the medication regimen. Adherence with at least 90% of medication doses was associated with a virologic response.