摘要:

Unintended pregnancy and subsequent abortion remain major public health issues in many countries, despite evidence that post-coital emergency contraceptives have a good safety profile, are easy to use, and are effective in preventing unwanted pregnancies. Although emergency contraceptives have been prescribed in developed countries for more than 25 years, abortion rates have continued to rise steadily in many jurisdictions. Barriers to the use of emergency contraceptives reduce ready access of women to this birth control option. Because the effectiveness of emergency contraceptives is time dependent, establishing prescribing and dispensing mechanisms that are convenient to women is crucial to their ability to use the therapy in a timely manner.Emergency contraceptives in developed countries are traditionally prescribed by physicians in organized healthcare settings. In these countries, pharmacists are ideally situated to improve patient access to emergency contraceptives, since community pharmacies are widely available in both urban and rural settings and are open extended hours. Innovative initiatives using a variety of regulatory mechanisms now allow pharmacists a greater role in prescribing and distributing emergency contraceptives. In Washington State, USA, pharmacists entering into a collaborative drug therapy agreement with a physician or nurse practitioner can initiate emergency contraceptives based on a prescribing protocol. Several local programs in the United Kingdom have utilized accredited community pharmacists to supply emergency contraceptives using a patient group directive. In British Columbia, Canada, specially-certified pharmacists with independent prescriptive authority utilize an informed consent during the interactive consultation with the potential emergency contraceptive user. In yet other jurisdictions, emergency contraceptives have been transferred to over-the-counter (OTC) status.Relevant public health research questions can now be posed. Future studies will be able to compare the effectiveness of various regulatory mechanisms to expand access, to identify and address potential drawbacks of pharmacist-initiated1emergency contraceptives, and to explore whether pharmacist-initiated prescriptions represent expanded access or simply a transfer of the prescribing of these agents from physicians to pharmacists. Countries with OTC emergency contraceptives will be able to explore the relationship between varying levels of pharmacist interaction with emergency contraceptive users and health outcomes, and to investigate whether the change in prescriptive status has resulted in unintentional barriers to access for populations such as teenagers and those with restricted discretionary income. These findings will provide valuable new information on the impact of initiatives designed to expand access to emergency contraceptives.

ISSN:1173-8790    

出版商:ADIS    

年代:2002

数据来源: ADIS

摘要:

The growing burden of chronic illness has contributed to increasing healthcare costs in the past two decades. Disease management can play an important role in reducing the growth in costs while at the same time improving outcomes. It is important that disease management companies accurately measure the financial impact of their program interventions in order to provide evidence that costs are reduced in the participant population because of the interventions.The most satisfactory method for evaluating the impact of disease management programs is a randomized controlled study. Unfortunately, randomized controlled studies can be costly, time-consuming and not morally acceptable for some clients. On the other hand, performing financial evaluations of a program without using a control group can be misleading and result in inefficient use of resources. The next best alternative to a randomized controlled study is to perform a retrospective pre-post control study. The key focus of a retrospective study is identifying a control group that is similar in socioeconomic, clinical and demographic characteristics to the intervention group. It is important not to use patients in the control group who refuse to participate in the program, because of self-selection biases that can be difficult to overcome.In this article, a high-risk coronary artery disease management program is used as an example in designing and implementing a retrospective financial outcomes study. The main hurdle to overcome was identifying a suitably large control group that had characteristics similar to the intervention group. Regression analysis was used to adjust for additional differences between the two groups.The results provide evidence that a retrospective pre-post control study can be a feasible alternative to costly randomized controlled studies. Although not reaching statistical significance at the usual 5% level, which is a limitation likely to be due to the small sample size, the sample study estimated total cost savings to be $US504 per member per month (PMPM). This represents an annualized saving of $US1 016 064 for the 168 members in the intervention group.

ISSN:1173-8790    

出版商:ADIS    

年代:2002

数据来源: ADIS

摘要:

Medication compliance is a classic problem for patients and healthcare providers and little progress has been made in improving it. The objective of this review is to enhance the understanding of medication compliance by means of a complex systems approach. The complex system approach includes seven underlying variables that are most likely to influence medication compliance:1. Knowledge: understanding how to use medication may be essential for compliance, but knowledge of disease or its treatment may also enhance concerns regarding prognosis or adverse effects of medication. However, various studies have failed to show a positive relationship between additional knowledge of the disease or its management and improved medication compliance.2. Illness beliefs: attitudes and beliefs about disease are crucial for compliance, but a patient's beliefs may be conflicting. Moreover, compliance behavior is influenced by automatic, environmentally controlled cues, or by irrational beliefs or rules of thumb, rather than logical reasoning.3. Symptom perception: accurate perception may be essential for compliance.4. Anxiety: modest concerns about health improve compliance whereas anxiety or indifference with regard to symptoms can have adverse effects on compliance.5. Control of symptoms and/or disease and self-efficacy: confidence regarding the management of health problems may be desirable in improving compliance. However, patients with a high sense of control may underuse medications. The exact role of self-efficacy in compliance is unclear.6. Medication efficacy: patients should perceive that the relief of symptoms or control of disease with a medication is in excess of its adverse effects in order for good compliance.7. Patient-physician/pharmacist congruence: patients should feel that they have the support of their physician and pharmacist in managing their disease.In addition to these variables, social support is commonly advocated as a determinant of medication compliance.In conclusion, mutual influences, interactions and nonlinear features of the different variables mentioned above warrant a holistic approach from healthcare providers to the analysis and improvement of medication compliance.

ISSN:1173-8790    

出版商:ADIS    

年代:2002

数据来源: ADIS

摘要:

Despite recent advances in the therapeutic management of asthma, the prevalence, morbidity and mortality of this chronic disease continue to increase in most countries. The financial burden associated with asthma has received increasing scrutiny in the medical literature over the past two decades. In 1990, a study in the US demonstrated that all chronic disease conditions accounted for $US425 billion in medical care costs. These chronic conditions accounted for 96% of home care visits, 80% of hospital days, 69% of hospital admissions, 66% of doctor and 55% of emergency department visits, and 55% of pharmacy prescriptions. This has led to an increased demand for improved outpatient management of asthma, and patients are now monitoring their asthma and gathering data in the ambulatory setting. Self-monitoring tools for patients with diabetes mellitus and hypertension have grown in recent years, but technological advances for self-monitoring of patients with asthma have been slow over the past several decades.This article reviewed the literature on self-monitoring tools currently available for improving outcomes in the patient with asthma. These tools currently consist of written treatment plans, peak flow meters and metered-dose inhaler monitoring devices. Patient education and training in self-management involving self-monitoring of either symptoms or peak expiratory flow, in conjunction with education and a written treatment plan, appears to improve health outcomes for both children and adults with asthma. Education allowing patients with asthma or their caregivers to intervene and adjust medications under the guidance of a written treatment plan appears to be more effective than other forms of asthma self-management.

ISSN:1173-8790    

出版商:ADIS    

年代:2002

数据来源: ADIS

摘要:

Parkinson's disease, a movement disorder caused by degeneration of nigrostriatal dopaminergic neurons in the substantia nigra, is characterized by resting tremor, rigidity, bradykinesia and postural instability. For over 30 years levodopa has been considered as the first-line treatment for this condition, but long-term treatment is complicated by the development of motor fluctuations and hyperkinesias. For patients with Parkinson's disease, entacapone reduces the peripheral metabolism of levodopa by inhibiting catechol-O-methyl transferase and, thus, prolonging the bioavailability of levodopa in the CNS.In patients with Parkinson's disease who have motor fluctuations, entacapone significantly increases the duration of "on" time, reduces that of "off" time and reduces mean daily intake of levodopa compared with placebo treatment. Data from the Unified Parkinson's Disease Rating Scale indicate that treatment with entacapone is associated with improved activities of daily living and motor disability scores. In clinical studies, entacapone is not associated with elevation of liver enzymes or changes in other clinical chemistry parameters. Gastrointestinal (such as nausea and diarrhea) or CNS (such as hallucinations and worsening of dyskinesias) adverse events with entacapone are of mild to moderate severity and usually subside with adjustment of the levodopa dosage.Pharmacoeconomic evaluations also suggest that entacapone is a viable treatment option in Parkinson's disease. Two Markov state transition studies suggest that the increased drug costs incurred when entacapone is added to a patients' treatment regimen would be at least partially offset by savings in other healthcare sectors such as inpatient care. Both studies predicted that treatment with entacapone would result in an increase in quality-adjusted life years.The clinical and economic data clearly support the use of entacapone in combination with levodopa in patients with Parkinson's disease. However, a levodopa-sparing strategy is favored by many clinicians in an attempt to offset the development of motor fluctuations in later years and thus dopamine agonists are often employed in monotherapy and in combination with lower dosages of levodopa. The use of COMT inhibitors should lead to an increase in the duration of clinical effect of each individual levodopa dose, a consequent reduction in the frequency of levodopa administration, and ultimately to a potential reduction in the development of motor fluctuations.

ISSN:1173-8790    

出版商:ADIS    

年代:2002

数据来源: ADIS

ISSN:1173-8790    

出版商:ADIS    

年代:2002

数据来源: ADIS