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Background: Although lack of time, trained personnel, and reimbursement have been identified as barriers to pharmacists providing cognitive pharmaceutical services (CPS) in community pharmacies, the underlying contributing factors of these barriers have not been explored. One approach to better understand barriers and facilitators to providing CPS is to use a work system approach to examine different components of a work system and how the components may impact care processes., Objectives: The goals of this study were to identify and describe pharmacy work system characteristics that pharmacists identified and changed to provide CPS in a demonstration program., Methods: A qualitative approach was used for data collection. A purposive sample of 8 pharmacists at 6 community pharmacies participating in a demonstration program was selected to be interviewed. Each semistructured interview was audio recorded and transcribed, and the text was analyzed in a descriptive and interpretive manner by 3 analysts. Themes were identified in the text and aligned with 1 of 5 components of the Systems Engineering Initiative for Patient Safety (SEIPS) work system model (organization, tasks, tools/technology, people, and environment)., Results: A total of 21 themes were identified from the interviews, and 7 themes were identified across all 6 interviews. The organization component of the SEIPS model contained the most (n=10) themes. Numerous factors within a pharmacy work system appear important to enable pharmacists to provide CPS. Leadership and foresight by the organization to implement processes (communication, coordination, planning, etc.) to facilitate providing CPS was a key finding across the interviews. Expanding technician responsibilities was reported to be essential for successfully implementing CPS., Conclusions: To be successful in providing CPS, pharmacists must be cognizant of the different components of the pharmacy work system and how these components influence providing CPS., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Background: Under the 1995 Wisconsin Act 27, the biennial budget, Wisconsin Medicaid was required to develop an incentive-based pharmacy payment system for pharmaceutical care (PC) services. Started on July 1, 1996, the Wisconsin Medicaid Pharmaceutical Care Program (WMPCP) is the longest currently ongoing Medicaid program to compensate pharmacists for nondispensing services. The program reimburses pharmacies for providing PC services that increase patient compliance or prevent potential adverse drug problems by paying an enhanced PC dispensing fee. Pharmacists can bill for PC services provided to Wisconsin Medicaid fee-for-service and SeniorCare (i.e., state prescription drug assistance program for low-income seniors) beneficiaries., Objectives: To examine trends in (a) the number of pharmacies participating in the WMPCP and the intensity of participation among participating pharmacies; and (b) frequencies of reason, action, result, and level-of-service (time) codes associated with PC service claims from July 1, 1996, through June 30, 2007, which represents Wisconsin state fiscal years (SFYs) 1997 through 2007., Methods: A retrospective, longitudinal, and descriptive research design was used to analyze all paid claims for PC services provided to Wisconsin Medicaid fee-for-service and SeniorCare recipients during SFYs 1997 through 2007. The total number of paid PC claims and the average number of claims paid per pharmacy were examined to determine trends in pharmacy participation. Mean annual reimbursement amounts for PC per claim and per pharmacy were calculated. Reason, action, result, and level-of-service (time) codes that appeared in the claims were grouped into categories and analyzed to characterize the total number of claims paid overall and per SFY., Results: During the study period, one-half (n = 601) of the approximately 1,200 licensed pharmacies in the state of Wisconsin were paid for a claim through the WMPCP. However, intensity of participation in the WMPCP was low, with 57% of all participating pharmacies being paid for 10 or fewer PC claims and 19% paid for only 1 PC claim over the 11-year study period. The growth in claims per year coupled with smaller growth in the number of participating pharmacies resulted in a trend of growth in the mean number of claims per participating pharmacy in the program. The proportion of total WMPCP claims accounted for by the top 10 pharmacies with the highest volume of PC claims varied from 46.6% to 80.2% per year. Patient behaviors (e.g., early or late refills) and drug use issues/problems (e.g., patient complaints or symptoms) were the most common reasons for pharmacists to provide PC services (62% of all PC claims), although drug choice reasons (e.g., product selection opportunity) were more common after 2004. The majority (55.1%) of PC services took 15 minutes or less of pharmacists' time. The total dollar amount paid to pharmacies for PC services was $876,822 between SFYs 1997 and 2007, with an overall mean of $1,459 paid per participating pharmacy., Conclusions: Trends in pharmacy participation and claims volume showed growth, albeit limited, in PC program participation with a majority of paid claims dealing with patient behaviors and drug use issues or problems that consumed a small amount of pharmacists' time (15 minutes or less). The intensity of participation (claims per pharmacy) increased over time, suggesting that some pharmacies may have developed effective systems for participating and successfully submitting claims to WMPCP for enhanced dispensing fees. Further evaluation of the impact and implications of this program for patients, pharmacists, and the state is needed to gauge overall program success and provide evidence or guidance for continued or expanded PC initiatives.

Background: For the last decade, there has been a shortage of pharmacists for most of the United States. This shortage is in part because of demand-side phenomena (eg, increasing prescription drug use, increases in the complexity of drug regimens, and an aging population). However, there also may be supply-side causes. Although the number of pharmacy school graduates has increased, most graduates are women, many of whom may choose to work part-time. Because of the change in sex composition of the workforce, some researchers conclude that pharmacist shortages will be even more critical in the future., Objectives: The goals of this article are to model pharmacists' decisions to work, estimate pharmacists' wages, and identify influences on the number of hours worked by pharmacists in the United States., Methods: Pharmacist labor supply is examined using a static, 3-step, empirical labor supply model that estimates the decision to work, hourly wages, and number of hours worked for U.S. pharmacists., Results: Pharmacists have high starting wages but flat wage trajectories. Although many pharmacists are working part-time, this is true for women and men. Income effects do not dominate substitution effects, even at the high level of compensation found here., Conclusions: Results indicate that previous predictions brought about by the changing sex composition of the pharmacist labor force might not come to pass, and additional pharmacists may be attracted to the profession by higher wages and flexible schedules., (Copyright © 2011 Elsevier Inc. All rights reserved.)

Objective: To determine whether growth in the number of pharmacy graduates and newly accredited schools from 2000 to 2009 were larger in states with fewer pharmacists per population age ≥ 65 years., Methods: States were aggregated into quartiles based on rank-ordered ratios of in-state pharmacists per 100,000 population aged ≥ 65 years. Quartiles were then compared with respect to the number of new graduates., Results: The mean cumulative number of graduates was highest in the first quartile of states (those with the greatest need for pharmacists) and lowest in the fourth quartile of states. States with the greatest need for pharmacists had the lowest positive growth in number of pharmacists per population ≥ 65 years. The majority of new schools in 2009 were located in states with relatively low numbers of pharmacists., Conclusion: The growth in new pharmacy graduates created by expansion in schools as well as in graduates per school helped states meet demand between 2000 and 2009. However, tremendous variation remains in the number of graduates as well as the number of pharmacists across states. The quartile framework is useful for assessing the number of new pharmacy graduates based on pharmacists per population ratios. Based on current dynamics in the supply and demand of pharmacists, frequent monitoring is recommended.

Objectives: To assess pharmacists' provision of antidepressant information and to examine the effect of patient ethnicity and language skills on pharmacists' provision of information and patient education., Design: Cross-sectional, randomized, between-subjects study., Setting: Wisconsin, from September to November 2008., Participants: 540 community pharmacists., Intervention: Participants were exposed to one of three vignettes describing a patient coming into the pharmacy for an initial dispensation of an antidepressant. Vignettes varied according to patient ethnicity (white or Hispanic) and language spoken (English or Spanish)., Main Outcome Measures: Respondents' information and education messages given to patients about antidepressants and whether Hispanic patient ethnicity and English language ability reduced pharmacists' communication about antidepressants., Results: A majority of participants would provide information regarding the medication's name (93.3%) and dosage schedule (92.8%). Many pharmacists also reported that they would tell the patient to take the medication on a daily basis (92.6%) and that it takes 2 to 4 weeks for the medication to have a noticeable effect (87.8%). Multivariate models showed that pharmacists would provide significantly less information (β = -0.24 [95% CI -0.31 to -0.17]) and education messages (-0.17 [-0.24 to -0.09]) to Spanish-speaking patients., Conclusion: These findings suggest that Spanish-speaking patients may face disparities in the level of care received from community pharmacists. Interventions should be available to enhance pharmacists' communication with Spanish-speaking patients in an effort to facilitate safe and effective medication use.

This clinical report describes the multidiscipline treatment for a 19-year-old service member who entered the military diagnosed with dentinogenesis imperfecta. The patient presented with multiple teeth with extensive dental caries, considerable sensitivity, and an inability to function due to the extent of the dental disease. The goal of the treatment was to restore function and aesthetics. A combined treatment approach was initiated which involved prosthodontics, periodontics, and dental implant therapies. Functional and aesthetic results were achieved.

Objective: To determine (1) the frequency of the different types of drug therapy modification claims paid by a pharmacy benefits manager (PBM), (2) PBM cost savings and return on investment (ROI), and (3) patient savings from pharmacist-reimbursed drug therapy modifications., Design: Cross-sectional, retrospective, descriptive study., Setting: Midwest United States in 2006., Patients: Not applicable; 767 paid therapeutic interchange service claims from the PBM database were analyzed., Intervention: Descriptive statistics for PBM costs and cost savings to the PBM and to patients were calculated using all prescription fills., Main Outcome Measure: ROI calculated by dividing net savings across all fills by net costs., Results: Claims were paid to pharmacists for drug therapy modifications to allow tablet splitting, drug therapy changes, and switching noncovered drugs. Tablet splitting provided the largest cost savings to the PBM, accounting for slightly more than one-third of the claims and representing more than one-half of the prescription fills. Switching drugs not covered provided the largest cost savings to patients. Overall, the PBM saved a mean of $20.31 per prescription fill, and patients saved $14.76 per prescription fill. Mean overall ROI to the PBM was 3.55., Conclusion: Payment for pharmacist interventions can be an economic benefit for both patients and third-party payers. The cost savings for payers likely will dictate the endorsement of pharmacist-reimbursed programs and economic incentives offered to pharmacists and pharmacies.

Objective: To compare practice settings and activities of pharmacists with bachelor of science (BS) in pharmacy and doctor of pharmacy (PharmD) degrees., Methods: Data from the 2009 National Pharmacist Workforce Survey instrument were analyzed. Multivariate regression was used to examine the association of the PharmD degree with time spent in dispensing and patient care., Results: The survey response rate by pharmacists was 52%, and 562 usable responses met our inclusion criteria. Sixty-three percent of BS and 39% of PharmD pharmacists were employed in community pharmacies, compared with 21% of BS and 38% of PharmD pharmacists employed in hospital pharmacy settings. Practicing in a community setting had the strongest influence on time spent in dispensing and time spent in patient care. Among respondents with PharmD degrees, a residency was associated with less time in dispensing and more time in patient care., Conclusion: Time spent in dispensing and patient care were influenced more by practice setting than by educational degree and residency training.

Background: Measuring community pharmacists' self-efficacy in performing medication therapy management (MTM) services can be useful for tailoring interventions and predicting participation., Objective: To identify relevant survey constructs related to the Wisconsin Pharmacy Quality Collaborative (WPQC) MTM program and to evaluate scale validity., Methods: The 31-item MTM self-efficacy scale was developed using previous research, identifying critical program components, and beta testing. After administration to pharmacists in the 53 WPQC pilot sites, summary statistics and exploratory factor analysis (EFA) were conducted. Parallel analysis was used to determine the optimal number of factors. Internal consistency reliabilities were calculated., Results: Baseline participation rate was 94% (N=76). The 11-point scale (0-10) item means ranged from 2.83+/-3.05 to 7.82+/-2.19. Parallel analysis produced a 3-factor solution, accounting for 56% of the variance. Low-factor loadings or unacceptably high cross loadings resulted in 17-item deletions. The final EFA on the remaining 14 items retained the original 3-factor solution and increased the proportion of explained variance (72%). The factors relate to MTM tasks (alpha=0.92), personal interactions (alpha=0.86), and goal setting (alpha=0.84). Overall Cronbach's alpha=0.90., Conclusion: Constructs for measuring self-efficacy were identified that may aid in future research predicting whether pharmacists engage in and persist in providing MTM services., (Copyright 2010 Elsevier Inc. All rights reserved.)

Background: Medicare Part D was expected to have differential impacts on patient drug expenditures and use based on beneficiaries' levels of pre-Part D patient drug spending, but it is unknown whether these projections have borne out., Objectives: We sought to evaluate whether and how the policy effect of Medicare Part D on drug expenditures and use was modified by levels of pre-Part D drug spending., Methods: A quasi-experimental, pretest-posttest, nonequivalent control group design was used. Data were obtained from a regional supermarket chain for all prescriptions dispensed between January 1, 2005, and December 31, 2007 (n=1,230,612) to patients aged 60 years and older as of January 1, 2005 (n=51,305) to construct 12-month pre-Part D and post-Part D periods. Annual medication use was measured as the total number of pill days acquired. Annual drug expenditures were measured as total expenditures, patient out-of-pocket expenditures, and the proportion of total expenditures paid out of pocket by the patient., Results: Part D resulted in significant reductions in out-of-pocket spending (17.6%) and significant increases in drug use (4.0%) for individuals in the highest pre-Part D drug-spending group relative to controls. The reduction in out-of-pocket spending for the highest pre-part D spending group was significantly greater compared with the moderate and lowest pre-Part D spending groups., Conclusions: Our findings suggest that, as expected, Part D facilitated access to medications for patients who previously experienced the greatest costs without adversely increasing use and costs among those with the lowest prior cost., (Copyright 2010 Elsevier Inc. All rights reserved.)

Context: Higher prevalence of chronic diseases and reduced access to other health professionals in rural areas suggest that rural Medicare enrollees will benefit from pharmacist-provided drug therapy services (DTS)., Purpose: The purpose of this study was to describe non-metropolitan community pharmacy sites in Wisconsin, the provision of DTS at these sites, and to identify factors associated with provision of DTS., Methods: A cross-sectional, descriptive survey design was used to collect primary data in 2005. The manager/owner listed for each of the 279 non-metropolitan community pharmacy sites in Wisconsin was surveyed using an 8-page instrument. The 7 drug therapy services that key informants were asked to report on included 6 disease state management (DSM) programs and medication therapy management services (MTMS). Descriptive statistics were calculated for variables describing the pharmacy sites and how DTS were provided. Logistic regression was performed, with any drug therapy service provision as the dependent variable and 8 independent variables., Findings: The response rate to the survey was 44%. Overall, 31% of the respondent pharmacies offered MTMS and 31% offered DSM programs. Higher service orientation, location in a more rural area, and lower workload per pharmacist were significantly positively related to provision of any DTS., Conclusions: Conducted 4 months prior to the implementation of Medicare Part D, the results serve as a baseline against which the effects of Part D on MTMS provision may be evaluated. The negative association of pharmacist workload with pharmacy provision of DTS, coupled with the current pharmacist shortage, has important implications for patients' access to these services in rural areas.

Background: Understanding the effects of job stress continues to be a concern for health-care providers as workload and personnel needs increase., Objective: The overall objective of this study was to test a direct effects model of job stress that examines the characteristics of the organizational environment (interpersonal interactions, environmental aspects, the level of compensation and advancement, role stress, and availability of alternative jobs); extra-role factors (work-home conflict); job stress; individual factors (career commitment); and the work-related psychological outcomes of job satisfaction, organizational commitment, and job turnover intention., Methods: A cross-sectional mail survey was sent to a nationwide random sample of 4895 licensed pharmacists in the United States. Previously validated summated Likert-type scales measured each of the study variables. Data analyses included descriptive statistics, and exploratory and confirmatory factor analyses. Structural equation modeling was used to estimate the final model., Results: A response rate of 46% was achieved. Psychometric analyses indicated acceptable reliability and validity. The study model fit the data well (CFI[comparative fit index] = 0.90, RMSEA[root mean square error of approximation] = 0.05). Organizational factors in the form of role overload (standardized beta = 0.45) and conflict (0.31) and ease of finding a job with better interpersonal characteristics (0.26) had the largest effects on job stress. Interpersonal characteristics were also one of the strongest predictors of job satisfaction (-0.61) and organizational commitment (-0.70). Work-home conflict directly affected job turnover intention (0.11) and career commitment (-0.16). Other significant, but sometimes, opposite direct effects were found. Job satisfaction and organizational commitment directly affected job turnover intention., Conclusions: Given the increased demand for pharmacy services, health-care organizations will benefit from increasing positive and reducing negative work outcomes. Increased focus on enhancing interpersonal interactions, developing commitment to the profession, and greater consideration of nonwork factors could help pharmacists better manage their work environments. Future research should continue to refine these models to further enhance our understanding of the effects of job stress in the health professional workplace.

Objectives: To measure and describe the level of unmet demand for pharmacists in rural Wisconsin community pharmacies and to examine determinants of the level of unmet demand in these pharmacies., Design: Cross-sectional descriptive study., Setting: Community pharmacies (n = 279) located in rural Wisconsin counties in fall 2005., Participants: Key informants (managers/owners) identified for all sampled pharmacies., Interventions: A one-page participation form and an eight-page survey instrument were used to collect primary data about the level of unmet demand for pharmacists and internal pharmacy factors. Secondary data sources were used to extract information on external pharmacy factors., Main Outcome Measures: Presence of pharmacist vacancy, number of full-time equivalent (FTE) pharmacist positions vacant, and vacancy rate. Internal pharmacy characteristics included wage, prescription volume, prescription workload/pharmacist, dispensing-aiding technologies, technicians per pharmacist, practice setting, pharmacist FTE requirement, and pharmacist satisfaction. External pharmacy characteristics included population per pharmacy, seniors per pharmacy, per capita income, and rurality. The internal and external pharmacy characteristics were regressed on whether a vacancy was present and the vacancy rate (percentage of pharmacist FTEs unfilled)., Results: Overall response rate to the survey was 43.9%. One-third of the respondent pharmacy sites reported a pharmacist vacancy, most often 1.0 or less FTE. Pharmacist FTE requirement had a significant positive association with the presence of any pharmacist vacancy at a site. Prescription workload per pharmacist was positively related to the vacancy rate, while daily prescription volume and pharmacist satisfaction were negatively related to the vacancy rate., Conclusion: Overall, for rural community pharmacies in Wisconsin, a greater need for pharmacists at a site appears to make that site more likely to have a pharmacist vacancy. Pharmacist vacancies appear to have a greater impact on pharmacies that have a lower number of FTE pharmacist positions compared with pharmacies with higher FTE pharmacists because, potentially, fewer pharmacists are present to redistribute the workload.

Objective: To describe the nature of the collaborations between academia and practitioners in two community pharmacy practice-based research networks (PBRNs)., Setting: Community pharmacy practice sites owned by two pharmacy chain corporations that have cooperated with two pharmacy schools for up to 10 years in research efforts., Practice Description: A PBRN is a group of community pharmacy practice sites that are affiliated with an academic institution(s) that investigate questions related to community practice., Practice Innovation: A model of collaboration between academia and community pharmacy practice to enhance PBRNs. Collaborators in academia include practice and science faculty. Collaborators in community pharmacy practice include practitioners and practice-site decision makers., Main Outcome Measures: The role of each collaborator in the PBRN, suggestions for developing and maintaining collaborations among PBRN members, strategies to identify collaborators and to expand a PBRN, and the value to each collaborator of participating in a PBRN., Results: Academically based pharmacy faculty members connect with practice sites and listen to the needs of practitioners in an effort to design research that will solve practice problems. Practitioners and practice-site decision makers need to understand the role of research in solving projects, propose problems to be addressed and methods to address them, and become committed to completing the research. Building partnerships among collaborators is an important step in developing and maintaining the pharmacy-based PBRN. For faculty members, the value is connecting with community practice, helping to solve problems, and sharing results with the pharmacy community. For practitioners, the value of collaboration centers on improving practice and expanding their professional role., Conclusion: The involvement of community pharmacy sites with PBRNs has the potential to be a driving force in practice innovation, improving patient care and professional satisfaction.

Objectives: To examine the association between individual (demographic) and organizational (work environment and workload) factors and pharmacists' future work plans and explore reasons for either leaving or staying with current employers (culture/climate factors)., Design: Cross-sectional study., Setting: United States in 2004., Participants: 1,263 pharmacists., Intervention: Seven-page mail survey., Main Outcome Measures: Future work plans, time spent in practice activities, staffing levels, and actual and perceived workload and demographic variables., Results: Overall, 15% of respondents reported that they planned to leave their current employer within the year subsequent to this survey. More than 50% reported that their workload had significantly increased in the previous year. Multivariate analyses showed that nonwhites were 2.1 times more likely to be planning to leave their current employer, compared with whites, and unmarried respondents were 1.7 times more likely to leave than were married individuals. More negative perceptions regarding the impact of workload on various personal, work, and patient care outcomes predicted leaving. A main factor that prompted their inclinations was described by 72% of leavers (insufficient and/or unqualified staff) and 49% of stayers (flexible scheduling). The most common reasons for staying were good salary and relationships with coworkers, while the most common reasons for leaving were a desire for change and stress/workload issues., Conclusion: Future work plans of pharmacists are influenced by a variety of individual, organizational, and culture/climate factors. While employers have little latitude for influencing demographic characteristics of employees, many organizational and culture/climate factors (scheduling, opportunities for interpersonal interactions, salary/benefits, staffing, and workload) can be addressed with the intent of reducing pharmacist turnover.

Objectives: To describe the mix of pharmacy services being offered in different types of community pharmacy practices and to identify factors associated with a community pharmacy offering pharmacy services., Design: Cross-sectional study., Setting: Community pharmacies (independent, chain, mass merchandiser, and supermarket pharmacies)., Participants: Pharmacists practicing full-time or part-time who worked in community pharmacies and responded to the 2004 National Pharmacist Workforce Survey., Intervention: Mailed survey from the 2004 National Pharmacist Workforce Survey, which included core content questions for all sampled pharmacists and supplemental surveys that included workplace questions for a selected subsample of pharmacists., Main Outcome Measures: Type and frequency of pharmacy services being offered in a community pharmacy, including dispensing and product-related services (e.g., specialty compounding), and pharmacist care services (e.g., immunizations, smoking cessation, health screening, medication therapy management, wellness screening, nutritional support, and disease management services)., Results: Four pharmacist care services were reported as being offered at more than 10% of community pharmacy practices: immunizations, smoking cessation, health screening, and diabetes management. The number of pharmacist care services offered at a community pharmacy was positively associated with having at least three pharmacists on duty, innovativeness of the pharmacy, status as an independent pharmacy, and status as a supermarket pharmacy. More than one half of the community pharmacy practices did not offer any of the eight pharmacist care services included in a pharmacy service index., Conclusion: Pharmacy services were reported at relatively few community pharmacies, and were associated with pharmacy innovativeness, pharmacist staffing levels, and pharmacy setting. Some community pharmacies are offering pharmacy services as part of their business strategy, while others are dedicated to dispensing services. Continued study of pharmacy service availability in community pharmacies is needed to improve our understanding of our capacity to deliver such services, including medication therapy management services.

Objective: To examine work variables for licensed pharmacists for 1990, 2000, and 2004., Design: Three cross-sectional, descriptive studies., Setting: United States., Participants: Licensed pharmacists: 1,623 in 1990; 2,092 in 2000; and 1,564 in 2004. These numbers of usable responses to the three respective surveys represented 54.0%, 42.7%, and 33.8% of those receiving surveys., Intervention: Mailed survey from the 2004 National Pharmacist Workforce Survey; data from the national studies of the pharmacist workforce conducted in 1990 and 2000., Main Outcome Measures: Characteristics of pharmacists; work setting, work position and age distribution of actively practicing pharmacists. Work status of licensed pharmacists; proportion actively practicing pharmacy. Proportion of pharmacists working part-time overall and by age group, weekly hours worked by actively practicing pharmacists, and full-time equivalents (FTEs) by age group. Proportion of pharmacists with secondary pharmacy employment; work setting, hours worked, and weeks worked in secondary pharmacy employment., Results: In each year studied, more than 86% of licensed pharmacists were actively practicing pharmacy. In 2004, the largest proportion of actively practicing women pharmacists was between the ages of 31 and 45, and the largest proportion of actively practicing men pharmacists was between the ages of 46 and 60. Across the survey years, the proportion of all actively practicing pharmacists working part-time increased, and the proportion of women working part-time was at least double that of men except in 2004. In 2004, the FTE contribution for women was 0.81 and 0.91 for men., Conclusion: The decrease in FTE contributions by all pharmacists and the aging of the male pharmacist population raise concerns about the adequacy of current and future pharmacist supply. As the demand for pharmacists continues to evolve, pharmacy must continue to monitor the pharmacist workforce to show how pharmacists react to changes to better inform projections of the pharmacist workforce.

Objectives: To describe pharmacists' work activities in the United States during 2004 in terms of (1) the desired amount of time they would like to spend in each of four work activities (medication dispensing, consultation, business management, drug use management), (2) the amount of time they actually spend in each activity, and (3) the gaps between desired and actual time reported in each activity., Design: Cross-sectional study., Setting: Pharmacies (community chain, community independent, hospital, and other) in the United States., Participants: 1,564 actively practicing pharmacists., Intervention: Mailed survey from portions of the 2004 National Pharmacist Workforce Survey., Main Outcome Measures: Differences between desired and actual time spent in work activities in medication dispensing, consultation, business management, and drug use management and the associations between practice setting characteristics and demographic variables were explored using linear and logistic regression analyses. Practice variables included position, years in current position, working part time, work with other pharmacists, work with technicians, proportion of staff who are pharmacists, staff size, dispensing level. Demographic variables included age, gender, race, marital status, and year of licensure with respondents' reported work activity amounts and gaps. Linear regression results were interpreted based on standardized beta coefficients and corresponding P values. Logistic regression results were interpreted based on 95% confidence intervals for odds ratios., Results: The proportion of time pharmacists devoted to medication dispensing, consultation, business management, and drug use management did not change between 2000 and 2004. Practice setting was the most consistently influential variable on pharmacists' work activities when controlling for other variables. Pharmacists in all practice settings would like to spend more time in consultation and drug use management and less time in medication dispensing, but compared with community pharmacists, hospital and other patient care pharmacists were less likely to report a gap between desired and actual time spent in dispensing activities. Age was a significant predictor of gaps between desired and actual time spent in various activities, but only the oldest age groups (ages of 60 or 70 years and older) were significantly different from the reference group of pharmacists aged 23 to 30 years., Conclusion: Pharmacists would like to devote more of their time to consultation and drug use management activities in community pharmacy settings but have not yet been afforded a full opportunity to engage in these activities to the extent that they desire.

Objectives: To describe characteristics of community pharmacists' current practice environments and pharmacists perceptions' about aspects of their work environments., Design: Cross-sectional study., Setting: Community pharmacies (independent, chain, mass merchandiser, and supermarket pharmacies) in the United States., Participants: 1,564 actively practicing pharmacists., Intervention: Mailed survey from the 2004 National Pharmacist Workforce Survey, which included core content questions for all sampled pharmacists and supplemental surveys that included workplace questions for a selected subsample of pharmacists., Main Outcome Measures: Hours the pharmacy was open; staffing; workload, perceptions of workload, and impact of the current workload on them and their work; equipment and technology available and used; and impact of equipment and technology at the practice site. Responses were compared with those from the 2000 National Pharmacist Workforce Survey., Results: Hours of operation varied across practice settings in 2004 and were similar to those reported in 2000. Pharmacist and technician staffing varied somewhat across settings, but overall pharmacists were working with more technicians in 2004 compared with 2000. The number of prescriptions personally dispensed daily (personal workload) increased for pharmacists in all practice settings from 2000 to 2004. When pharmacists reported the impact of their current workload, motivation to work at the pharmacy and job satisfaction were rated most positive, and opportunity to take adequate breaks were rated most negative. Equipment used for facilitating the dispensing process was more common in pharmacies than equipment related to patient care activities. More than one half of pharmacists reported that equipment and technology increased their level of productivity, quality of care, financial performance, and job satisfaction in the pharmacy., Conclusion: Pharmacists' work environments tend to be oriented toward traditional dispensing roles and activities. Staff, equipment, and information technology resources are available to facilitate both dispensing and patient care activities, and these resources have increased productivity, quality of care, and pharmacists' satisfaction.

Objectives: To provide a current profile of pharmacists' attitudes toward worklife and determine how demographic, family, and practice variables influence work attitudes., Design: Cross-sectional descriptive survey., Setting: Nationwide sample of licensed pharmacists in the United States., Participants: 1,737 actively practicing pharmacists., Interventions: Mailed survey., Main Outcome Measures: Previously validated rating scales were used to measure job satisfaction, job stress, work-home conflict, role overload, role ambiguity, and role conflict. Family variables included the number and age(s) of children and marital status; demographic variables included age, gender, race, years of experience, region, and degree; practice variables included setting, position, work status, and work activities., Results: Although 67.2% of pharmacists were satisfied with their job, more than 68% experienced job stress and role overload, and 48% experienced work-home conflict. The levels of role ambiguity, role conflict, and job stress were significantly higher in chain, mass merchandiser, and hospital settings relative to independent settings. Wanting to spend more time in consultation was most positively associated with role ambiguity, role overload, and role conflict and most negatively associated with job satisfaction. Gender, race, years of experience, marital status, and children also affected work attitudes., Conclusion: Those interested in the quality of worklife of pharmacists need to develop and implement realistic methods to decrease the role stress that pharmacists continue to face. Unless role stress of pharmacists is lessened, the profession may be endangering not only the physical and mental health of its current and future practitioners, but possibly compromising patient safety as well.

Background: People without prescription drug coverage face greater financial burdens and may sometimes be unable to follow the courses of treatment prescribed by their physicians. The U.S. legislature is considering Medicare coverage for prescription drugs and the use of managed care approaches for containing costs associated with senior citizens. prescription drug therapy., Objective: The purpose of this study was to describe selected characteristics of senior citizens. prescription drug payment and procurement., Methods: Data were obtained via mailed survey from national random samples of senior citizens in 1998 and in 2001. Descriptive statistics and regression analyses were used to describe relationships among study variables., Results: Of 2,434 deliverable surveys, 946 (39%) were returned. Of these, 700 (29%) respondents provided usable data for analysis. Results showed that in 2001, compared with 1998, the proportion of senior citizens without any prescription insurance coverage did not change significantly, 29% and 32%, respectively. However, the proportion of respondents with prescription drug coverage who had to share costs of prescriptions through copayments and coinsurance rose significantly, from 69% in 1998 to 89% in 2001. Between 1998 and 2001, the proportion of senior citizens using mail-order pharmacies rose significantly, from 17% to 27%, and the proportion who reported financial hardship also rose, from 19% in 1998 to 31% in 2001. Controlling for year, prescription drug use, and income, logistic regression analysis showed that respondents without any prescription insurance coverage were about 5 times more likely to report financial hardship compared with those having coverage., Conclusions: The proportion of senior citizens without any prescription drug insurance coverage did not change significantly between 1998 and 2001, but cost sharing in terms of the proportion that had cost-sharing requirements and the amount of the cost sharing through copayments and coinsurance rose significantly. Self-reported financial hardship and the use of mail-order pharmacies among seniors increased between 1998 and 2001.

Several proposals for adding a prescription drug benefit to the Medicare program rely on consumer choice and market forces to promote efficiency. However, little information exists regarding: 1) the extent of price sensitivity for such plans among Medicare beneficiaries, or 2) the extent to which drug-only insurance plans using various cost-control mechanisms might experience adverse selection. Using data from a survey of elderly Wisconsin residents regarding their likely choices from a menu of hypothetical drug plans, we show that respondents are likely to be price sensitive with respect to both premiums and out-of-pocket costs but that selection problems may arise in these markets. Outside intervention may be necessary to ensure the feasibility of a market-based approach to a Medicare drug benefit.

Using the 1996-1999 Medicare Current Beneficiary Survey, we examine trends in nonacquisition of prescribed medicines among seniors. Each year less than 3 percent of seniors reported not getting the medicines that were prescribed for them, most often for economic reasons, but they also noted reasons relating to their preferences about using medicines. The presence or absence of drug coverage and chronic disease did not appreciably change this percentage, which suggests that a Medicare drug benefit may not greatly increase seniors' acquisition of their prescribed medicines.

The factors contributing to the use of antiresorptive therapies (ARTs) and differentiating the ARTs used were examined. A list of names of community-dwelling persons 65 years or older living in Wisconsin was obtained, and 2100 individuals were selected (1050 men and 1050 women) to receive the 10-page survey instrument. The survey requested information on health status, prescription drug use, preferences for using prescription drugs versus self-treatment strategies, demographic characteristics, and status and type of prescription drug and medical insurance. Only the responses from female respondents were evaluated. Descriptive statistics were calculated for each variable. The simultaneous relationships among all variables were modeled sequentially using a binary logistic regression model and a multinomial logistic regression model. Usable responses were received from 629 women, yielding an adjusted response rate of 59.9%; 169 (26.9%) reported current use of at least one ART, 110 (17.5%) reported using hormone replacement therapy (HRT), and 59 (9.4%) were using newer ARTs. The typical respondent did not use any prescription medicines for the treatment or prevention of osteoporosis, was married, and did not have a four-year college degree. Married, younger women with high medical care preferences scores were more likely to use antiresorptive agents. Married women were more likely to use HRT versus no treatment. A higher number of family practice physicians per 100,000 population reduced the likelihood of the use of any ART. Lower age was also related to the use of ARTs. Marital status, age, medical care preferences, prescription drug insurance, a regular source of care, and the diagnosis of osteoporosis were all significantly associated with the use of any antiresorptive agent.

The purposes of this study were (1) to assess the utility of the economic theory of demand for insurance for modeling voluntary Medicare drug benefit enrollment decisions and (2) to explore the degree of adverse selection and crowd-out that might occur under a voluntary enrollment Medicare prescription benefit. Data were collected using a cross-sectional, mail survey of 2,100 community-dwelling adults aged 65 and older in Wisconsin. Respondents were asked to evaluate their likelihood of enrollment in any of 4 hypothetical drug benefit plans under the assumption that they could enroll in one of the hypothetical plans or maintain their current coverage. Data analyses included bivariate comparisons across enrollment likelihood categories and logit analysis of enrollment likelihood as a function of respondent characteristics. 1041 usable survey forms were returned for an adjusted response rate of 51.5%. Older adults with 4 or more chronic conditions were most likely to report that they were "very likely" to enroll in one of the hypothetical drug plans, as were those with the highest out-of-pocket drug spending in the previous 30 days. Respondents with no or self-purchased drug benefits were more likely than those with employer-based plans to express a higher likelihood of enrollment in one of the hypothetical plans. Adverse selection may be problematic for a voluntary enrollment Medicare drug benefit. Given that high out-of-pocket drug spending (secondary to drug coverage source) was a consistent predictor of enrollment likelihood, demand-side factors affecting the crowding out of employer-based drug coverage sources by a voluntary enrollment drug benefit appear minimal. However, the availability of a Medicare prescription benefit may still lead to crowd-out through employer incentives.

Objective: To describe existing prescription drug insurance coverage for older Americans, to describe out-of-pocket payment levels per prescription associated with service benefit prescription drug plans used by older persons, and to examine the association of prescription drug coverage types with the reported use of prescription drugs by older persons., Patients and Methods: Data were obtained from a national survey of 1570 community-dwelling older persons (>65 y) conducted in June 1998. A 2-part utilization model was estimated using logistic regression and ordinary least-squares regression., Results: Data from 310 respondents were used for analysis. Overall, 66.1% of respondents reported having prescription drug insurance coverage. A majority (76.6%) of respondents having private drug coverage reported having a service benefit plan (requiring copayment or coinsurance amount to be paid for each prescription). The median copayment per brand name and generic prescription for persons reporting having coverage by service benefit plans was $10 and $5, respectively., Conclusions: Overall, a majority of older persons reported paying relatively small amounts out-of-pocket per prescription during 1998. Among persons who reported having drug insurance coverage, there were no statistically significant differences in the reported number of drugs used daily, regardless of out-of-pocket payment amount per prescription. Patient need and level of past drug use were significantly associated with both the likelihood of using any prescription drugs and the level of use among users. More research is needed to examine differences in drug expenditures and characteristics of drugs used across prescription drug insurance types for older persons.

Objectives: The first objective of this study was to examine the prevalence of prescriptions that offer the opportunity for generic drug use (a prescription for a multisource drug product). The second objective was to examine the prevalence of generic drug use by examining the rate of generic drug prescribing for multisource drug products and the rate of generic substitution by pharmacists. The last objective was to examine the association of prescriber, pharmacist, insurance, patient, and drug variables with the prescribing of drugs allowing the opportunity for generic drug use and generic substitution., Research Design: A database containing information for 6380 prescription orders was used for analysis., Measures: Random-effects logistic regression panel data estimation was used to examine the association of independent variables with whether a prescription allowed the opportunity for generic drug use and whether a prescription allowing generic drug use and written using the brand name was generically substituted., Results: The opportunity for generic drug use existed for 63% of prescription orders. Prescriptions covered by private third party and indemnity insurance were 33% (97.5% CI, 0.56-0.80), and 21% (97.5% CI, 0.62-0.98), less likely, respectively, to allow the opportunity for generic drug use relative to uninsured prescriptions. Unobserved prescriber characteristics accounted for 23% (95% CI, 0.14-0.34) of the variance in the opportunity for generic drug use. Pharmacists generically substituted 83.8% of prescriptions that could be generically substituted. Prescriptions covered by Medicaid were 4.57 (97.5% CI, 2.83-7.39), 5.15 (97.5% CI, 3.25-8.13), and 4.85 (97.5% CI, 2.83-8.17) times more likely, respectively, to be generically substituted relative to uninsured, private third party and indemnity prescriptions. Unobserved characteristics of pharmacists accounted for 44% (95% CI, 0.33-0.55) of the variance in the occurrence of generic substitution., Conclusions: Pharmacists play a large and important role in generic drug use and efforts to increase generic drug use directed at pharmacists should be maintained. Additional efforts to increase generic drug use likely should be targeted at prescribers.

Objectives: To describe community pharmacists' work activities in the United States during 2000 and to investigate the effects of position, pharmacy type, and prescription volume on work activities., Design: Cross-sectional descriptive survey of a systematic sample of 4,895 U.S. pharmacists, of which 2,250 responded., Setting: United States., Participants: A sample of 832 community pharmacists working full-time (at least 30 hours per week) out of the total of 2,250 who responded to the survey., Interventions: Not applicable., Main Outcome Measures: Workload (hours worked and proportion of prescriptions dispensed at the site with which the pharmacist was personally involved) and professional responsibilities (proportion of time spent in medication dispensing, consultation, business management, and drug use management)., Results: As of 2000, the typical community pharmacist in the United States devoted 56% of his or her time to medication dispensing responsibilities, 19% to consultation responsibilities, 16% to business management responsibilities, and 9% to drug use management responsibilities. These results were consistent for pharmacists regardless of pharmacy type or prescription volume; however, position did significantly affect the proportion of time spent in the various activities., Conclusion: Pharmacists are still devoting the majority of their time to medication dispensing responsibilities. However, our findings also show that pharmacists would prefer to devote more of their time to professional responsibilities, such as consultation and drug use management, and less time to medication dispensing and business management.

Decalcified freeze-dried bone allograft (DFDBA), believed to serve as a matrix for new bone growth and to contain various bone-inducing growth factors, is currently used to regenerate periodontal defects and to restore and maintain dental alveolar ridges. Growth factors within DFDBA are extracted during the demineralization process, thus rendering the allograft incapable of spontaneous osteogenesis; however, exogenous growth factor addition to DFDBA may enhance the osteogenic capacity of native osteoblasts. This study's purpose is to evaluate murine osteoblast proliferation in the presence of various exogenous soluble growth factors as measured by fluorescence units. Osteoblasts harvested from mouse pup calvaria were cultured with 2% residual calcium-DFDBA and supplemented by one of the following growth factors or combinations of these factors: transforming growth factor-beta (TGF-beta), insulin-like growth factor-I (IGF-I), platelet-derived growth factor (PDGF), fibroblast growth factors basic (bFGF), or vascular endothelial growth factors (VEGF). Osteoblast proliferation rates indicate that the in vitro supplementation of 2% residual calcium-DFDBA with the combination of IGF and TGF-beta, IGF and PDGF, and PDGF and TGF-beta significantly (P < or = .05) enhance murine osteoblast activity and proliferation at 7 days compared with the control containing no exogenous growth factors.

Gingival fenestration is an opening through oral keratinized tissue, usually unattached, that is observed in thin gingiva with usually thick subgingival calculus deposits. This lesion is seen infrequently but may be more common than has been reported; lack of symptoms may inhibit patient awareness. Because surgical correction usually is not required, there are very few reports in the literature concerning this lesion. The following report describes a case of gingival fenestration and surgical treatment with a connective tissue/periosteal graft.

Purpose: The objectives of this study were to develop a theoretically derived model of hours worked by pharmacists and estimate the model separately for male and female pharmacists., Methods: A systematic random sample of 1,600 pharmacists from four states was mailed a survey asking about current and past employment information. Two dependent variables were studied: weekly hours worked and annual hours worked. Independent variables were categorized as economic variables (hourly wage rate, other income, total debt) and demographic variables (employment position, age, degree earned, marital status, number of children at home). A two equation multiple regression model was estimated with two-stage least squares regression., Results: A total of 541 pharmacists responded to the survey and data from 442 of the respondents were used in the analysis. Hourly wage rates were negatively associated with weekly hours worked for males. Other income and total debt were significantly negatively and positively associated, respectively, with annual hours worked by female pharmacists. The number of young children at home significantly reduced weekly and annual hours worked by female pharmacists. Female pharmacists earning a Pharm.D. degree worked significantly more hours weekly and annually. Age was significantly negatively associated with male pharmacists weekly and annual hours worked., Conclusions: Economic variables had a relatively small effect on hours worked by male and female pharmacists suggesting that increased wage rates may not increase hours worked. Strategies to increase hours worked by females likely should focus on benefits to help females handle childcare issues.

The first objective of this study was to assess the existence of nonresponse bias to a national survey of licensed pharmacists conducted in 2000. Three methods were used to assess nonresponse bias. The second objective of the study was to examine reasons why sampled licensed pharmacists did not respond to the national survey of licensed pharmacists. We used data from 2204 respondents to a national survey of pharmacists and from 521 respondents to a survey of nonrespondents to the national survey. We made comparisons between respondents for 5 variables: employment status, gender, age, highest academic degree, and year of initial licensure. Chi-square tests were used to examine differences in the 5 variables between respondents to the first mailing and second mailing of the survey, early and late respondents to the survey, and respondents to the survey and respondents to the nonrespondent survey. There were no significant differences between first mailing and second mailing respondents, but there were differences in each variable except year of licensure between early and late respondents. These differences likely were due to regional bias possibly related to differences in mailing times. There were differences between respondents and nonrespondents in terms of employment status and year of licensure. The main reasons for not responding to the survey were that it was too long or that it was too intrusive. Overall, the survey methodology resulted in a valid sample of licensed pharmacists. Nonresponse bias should be assessed by surveying nonrespondents. Future surveys of pharmacists should consider the length of the survey and the address where it is sent.

Periodontal plastic surgical techniques to obtain root coverage traditionally have utilized autogenous soft tissue grafts. Guided tissue regeneration (GTR) increasingly is being used as an alternative to soft tissue grafting in attempting root coverage. Resorbable membranes in GTR therapy prevent the need for a second surgery to harvest donor tissue. GTR membranes composed of collagen are effective barriers that add to the thickness of the overlying gingiva and possess platelet-aggregating properties that may help in early wound healing. The cases presented here demonstrate the treatment of gingival recession with a resorbable collagen membrane.

Purpose: Reports from various pharmacy labor market sectors suggest that the United States may be experiencing a shortage of pharmacists. To guide policy making and planning with respect to this shortage, it is necessary to develop a better understanding of the process by which pharmacists choose jobs. Using the economic theory of job matching, this study sought to understand how (a) attributes of the practice setting, (b) characteristics of pharmacists, and (c) regional and urbanization variables are associated with pharmacy practice setting choices., Methods: A secondary database containing information about employment characteristics and work histories of 541 pharmacists in four states was used. The data were augmented with information on the relative number of employment opportunities in each of three practice settings (large chain, institutional, and independent) in the year the respondent's most recent employment change occurred. Practice setting choices were modeled using multinomial conditional logit regression., Results: A total of 477 pharmacists represented in the database met the inclusion criteria for the study. Multivariate analyses showed that the impact of search costs and wage differentials varied with the practice setting chosen. Pharmacists choosing independent settings over large chain settings were more likely to be white and to have worked in an independent setting in their prior job. Pharmacists living in Oregon were less likely to choose institutional settings compared to those living in Massachusetts, whereas those living in areas with populations greater than 50,000 were more likely to choose institutional settings., Conclusions: Pharmacist job matching appears to be a complex process in which diverse factors interact to produce a final match. Our results suggest that the pharmacy labor market may actually be composed of two distinct labor markets: an ambulatory market and an institutional market.

Pharmacist job turnover from 1983 to 1997 was studied. Data were collected from a randomized 1997 mail survey of 1600 licensed pharmacists in four states (Ohio, Massachusetts, Oregon, and Alabama). The survey instrument included questions on pharmacist demographics, work schedules, salary, and work history. A total of 541 pharmacists responded, yielding an adjusted response rate of 34.5%. Information was provided on a total of 1697 jobs with start dates from 1931 to 1997. Pharmacist job turnover was fairly steady across the 1983-1997 period, averaging 11% annually. The average median tenure of pharmacists who left jobs was 32 months. The percentage of pharmacists leaving jobs and ranking stress as the reason for leaving increased, and the percentage of leavers ranking salary as the reason decreased. Women had a significantly higher annual turnover rate (15%) than men (9.7%), and they stayed in jobs for significantly less time (25.2 months) than men (56.5 months). There were no differences in turnover rates across practice settings. A larger percentage of pharmacists leaving jobs in large chain and institutional settings ranked stress as a reason for leaving than pharmacists leaving independent or small chain pharmacies. A larger percentage of pharmacists leaving independent or small chain pharmacies ranked salary as a reason than pharmacists in the other two settings. Pharmacist job turnover averaged 11% per year between 1983 and 1997. Pharmacists who left jobs typically stayed less than three years. The percentage citing stress as a reason for leaving increased, and the percentage citing salary decreased.

Objectives: To use drug/age criteria to determine (1) the prevalence of dispensing of drugs potentially inappropriate for use in elderly patients; (2) the dispensing rate of individual drugs considered potentially inappropriate for use in elderly patients; (3) the association between selected patient characteristics and the prevalence of potentially inappropriate drug dispensing., Design, Setting, Participants: A secondary database of 6,380 new prescription orders dispensed to patients of all ages in ambulatory pharmacies in a mid-western state was used retrospectively for the analysis. A total of 1,530 (23.9%) of the new prescription orders were dispensed to 1,185 elderly patients., Interventions: Not applicable., Main Outcome Measures: Name, strength, and daily dose of each drug dispensed were compared with drug/age criteria to determine whether a dispensed drug was inappropriate for use in elderly patients. The association of the rate of dispensing of potentially inappropriate drugs with characteristics of the elderly patients, including age, sex, race, number of comorbidities, and prescription drug insurance coverage type, was determined., Results: A total of 170 patients (14.3%) were dispensed potentially inappropriate medications. The three most common medications were propoxyphene and propoxyphene combinations, prescription and nonprescription antihistamines, and digoxin at doses > 0.125 mg/day. There was no statistically significant association between inappropriate drug dispensing and patient age, sex, race, number of comorbidities, and prescription drug insurance coverage type., Conclusion: Pharmacists can use drug/age criteria as a tool for an initial check to assess the appropriateness of drugs used by the elderly. Elderly patients appear equally at risk of using potentially inappropriate medications regardless of demographic, disease, or insurance characteristics.

Objective: To obtain primary care physicians' and community pharmacists' opinions of the Pharmacist Note, a model epilepsy patient profile maintained by the pharmacist and transmitted to the physician as needed, and the information it contains., Design: A cross-sectional descriptive study design was used for collecting and analyzing data. Separate surveys were developed and mailed to physicians and pharmacists., Participants: 554 primary care physicians and 114 community pharmacists in Ohio who interact regularly with epilepsy patients., Main Outcome Measures: Pharmacist and physician opinions on the Pharmacist Note program., Results: Physicians ranked seizure frequency as their most useful piece of information, followed by medication compliance and drug interaction screening. For medication profile and drug interaction screening, most physicians currently use themselves as their primary source of information, although a significant number would prefer to use pharmacists as information sources in these areas (p < .05). A majority (62%) would like to have pharmacists more involved in the care of their patients. Pharmacists identified lack of time and lack of appointments with patients, inadequate pharmacy staff, and insufficient reimbursement as barriers to implementing the Pharmacist Note program., Conclusion: Physicians desire pharmacist involvement in specific areas of care for patients with epilepsy, and the feasibility of implementing the Pharmacist Note and similar programs appears promising. However, pharmacists identified barriers to implementation, and these barriers need to be addressed if this type of program is to be successful.

Ohio pharmacy directors' attitudes about national voluntary pharmacy technician certification were surveyed. In May 1996 a questionnaire was mailed to all 224 hospitals in Ohio. The questionnaire contained 29 attitudinal statements constructed as forecasts of the effects of certification; pharmacy directors were asked to rate their level of agreement or disagreement with each statement using a 7-point Likert scale. The response rate was 61.4% (137 questionnaires returned). Respondents indicated modest agreement with 21 of 27 attitudinal statements and therefore had a generally positive view of certification. For example, they agreed that certification will improve technicians' knowledge, image, confidence, skills, and job satisfaction. They disagreed that certification will allow technicians to function independently, result in the replacement of pharmacist positions with technicians, or eliminate the need for on-the-job training of technicians. There were significant differences in scores between directors working at hospitals employing certified technicians and directors working at hospitals not employing certified technicians for only three statements. Overall, Ohio hospital pharmacy directors had positive attitudes about pharmacy technician certification.

Objective: To examine the impact on dipyridamole prescribing of a letter mailed to pharmacists and/or physicians., Design: Interrupted time series with control series., Setting: State of Wisconsin., Participants: Physicians and pharmacists caring for patients who were prescribed dipyridamole., Interventions: The state of Wisconsin was divided into four sections, three of which were designated as experimental regions (letter to physician only, letter to pharmacist only, and letter to both physician and pharmacist) and one of which served as a control region., Main Outcome Measures: Cost of drug per patient per month in ambulatory and long-term care populations., Results: For 763 long-term care and 586 ambulatory Medicaid patients, letters sent to both physicians and pharmacists resulted in significant reductions in dipyridamole expenditures relative to the control group. For long-term care patients, interventions directed at both physicians and pharmacists produced significant reductions in dipyridamole prescribing relative to interventions directed at physicians alone or pharmacists alone., Conclusion: Future DUR letter interventions designed to change prescribing habits would be more effective if they targeted both physicians and pharmacists, particularly in the long-term care setting.

This study examines the association between types of prescription drug insurance coverage and the unit cost of dispensed drugs. Logistic regression and ordinary least squares regression were used to assess differences in the use of brand name and generic drugs and the unit cost of dispensed brand name or generic drugs across four insurance categories: Medicaid, private third party, indemnity, and uninsured. The results show that private third-party and indemnity prescriptions were more likely to be dispensed with brand name drugs. Also, indemnity patients and the uninsured were dispensed brand name and generic drugs with lower unit costs. The findings have ramifications for the design of prescription drug insurance benefits and suggest that physicians may respond to the economic situation of their patients when prescribing drugs.

Objective: To determine the effectiveness of a drug utilization review (DUR) letter intervention sent only to physicians, sent only to pharmacists, or sent to both physicians and pharmacists in changing physician prescribing behavior for dipyridamole., Data Sources/study Setting: A Wisconsin Medicaid prescription drug database for data from March 1991 through May 1992 related to both long-term care and ambulatory patient settings., Study Design: The effects of a DUR letter intervention were tested using a field study, pre-post, nonequivalent control group, quasi-experimental design. The effects of the letter intervention in terms of dipyridamole expenditures (dollars reimbursed to pharmacies by Medicaid), expenditures for related drugs (aspirin, ticlopidine, sulfinpyrazone) and numbers of patients for whom dipyridamole was discontinued were examined across three experimental groups and a control group., Data Collection/extraction Methods: Dipyridamole expenditures for each study patient during a six-month preintervention and six-month postintervention period were collected from Medicaid prescription drug claims. Patients who had zero dipyridamole expenditures throughout the six-month postintervention period were classified as having had dipyridamole discontinued., Principal Findings: Letters sent to both physicians and pharmacists resulted in a greater percentage of patients discontinuing dipyridamole relative to controls and statistically significant differences in postintervention dipyridamole expenditures relative to controls in both the long-term care and ambulatory patient populations., Conclusions: Interventions that focus on another person in the drug use process in addition to the physician may have greater effects on a change in the prescribing of a targeted drug than letters to physicians alone.

Internal rates of return were used to examine the status of pharmacist supply in the United States between the years 1987-1991. Age-earnings profiles were estimated for pharmacists, college graduates and high school graduates. Rates of return to pharmacists and college graduates were compared and a ratio of the pharmacist rate to the college graduate rate was computed for each year. Results suggest a shortage of pharmacists in the United States. Enrollments in pharmacy schools and adopted changes in the training of pharmacists are discussed in relation to their effects on the pharmacist labour market.

Drug utilisation review (DUR) has been adopted as a mechanism for balancing cost containment and quality in prescription drug programmes. In this article we review published DUR reports in order to examine the cost effectiveness of DUR in an outpatient setting. DUR reports are defined either as DUR studies, which examine patterns of drug use, or as DUR programmes, which examine patterns of drug use and subsequent efforts to alter drug use. An adequate cost-effectiveness analysis (CEA) is defined as one that used multiple methods to measure and evaluate patterns of drug use, and/or efforts to alter drug use, and that also performed an analysis of the costs of the review or intervention methods employed, with a focus on efficiency. DUR studies and programmes that satisfied all the criteria and thus fit the framework for conducting CEA were included; others that satisfied only some of the criteria were examined for the insights that they could contribute to a study of costs relative to outcomes. We identified 14 reports that could be categorised as DUR studies. Only 3 of these examined more than 1 method of measuring and evaluating drug use, thereby potentially fitting the CEA framework, but none included a cost analysis. Of the other DUR studies, only 1 contained estimates of costs for the DUR method employed, but since it examined only 1 DUR method it did not satisfy the criteria for an adequate CEA. Although such studies provide information about different methods of identifying drug use patterns (a somewhat intermediate outcome), they do not provide insight into the cost effectiveness of methods designed to influence drug use. We identified 34 reports of DUR programmes. Only 5 of these reports fit the CEA framework; they examined multiple efforts to change drug use patterns (after identifying drug use patterns). None of them satisfied the criteria for an adequate CEA; in 3 of the reports no costs were provided, and the other 2 provided only partial input costs or costs for only some of the interventions designed to change drug use. DUR programmes were grouped by drug or drug use issue in an attempt to gain insights by comparing reports on similar drugs. The drugs or drug classes and number of reports reviewed were: cephalosporins (3); chloramphenicol (3); antiulcer drugs (2); dextropropoxyphene (2); tranquillisers (benzodiazepines) {3}; anti-infective agents (5); 'all drugs' (7); and other drugs/miscellaneous (9).(ABSTRACT TRUNCATED AT 400 WORDS)