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Objectives: To (1) provide medication therapy management (MTM) services to patients, (2) measure the clinical effects associated with the provision of MTM services, (3) measure the percent of patients achieving Healthcare Effectiveness Data and Information Set (HEDIS) goals for hypertension and hyperlipidemia in the MTM services intervention group in relationship to a comparison group who did not receive MTM services, and (4) compare patients' total health expenditures for the year before and after receiving MTM services.Design: Prospective study.Setting: Six ambulatory clinics in Minnesota from August 1, 2001, to July 31, 2002.Patients: 285 intervention group patients with at least 1 of 12 medical conditions using prestudy health claims; 126 comparison group patients with hypertension and 126 patients with hyperlipidemia were selected among 9 clinics without MTM services for HEDIS analysis.Intervention: MTM services provided by pharmacists to BlueCross BlueShield health plan beneficiaries in collaboration with primary care providers.Main Outcome Measures: Drug therapy problems resolved; percentage of patients' goals of therapy achieved and meeting HEDIS measures for hypertension and hypercholesterolemia. Total health expenditures per person were measured for a 1-year period before and after enrolling patients in MTM services.Results: 637 drug therapy problems were resolved among 285 intervention patients, and the percentage of patients' goals of therapy achieved increased from 76% to 90%. HEDIS measures improved in the intervention group compared with the comparison group for hypertension (71% versus 59%) and cholesterol management (52% versus 30%). Total health expenditures decreased from $11,965 to $8,197 per person (n = 186, P < 0.0001). The reduction in total annual health expenditures exceeded the cost of providing MTM services by more than 12 to 1.Conclusion: Patients receiving face-to-face MTM services provided by pharmacists in collaboration with prescribers experienced improved clinical outcomes and lower total health expenditures. Clinical outcomes of MTM services have chronic care improvement and value-based purchasing implications, and economic outcomes support inclusion of MTM services in health plan design. [ABSTRACT FROM AUTHOR]

Several healthcare organizations across Minnesota have developed formal pharmacogenomic (PGx) clinical programs to increase drug safety and effectiveness. Healthcare professional and student education is strong and there are multiple opportunities in the state for learners to gain workforce skills and develop advanced competency in PGx. Implementation planning is occurring at several organizations and others have incorporated structured utilization of PGx into routine workflows. Laboratory-based and translational PGx research in Minnesota has driven important discoveries in several therapeutic areas. This article reviews the state of PGx activities in Minnesota including educational programs, research, national consortia involvement, technology, clinical implementation and utilization and reimbursement, and outlines the challenges and opportunities in equitable implementation of these advances.

Labor market forces in pharmacy are affected by frictional unemployment (job turnover), structural employment forces that require new skill sets for employees, and hiring practices that integrate technology or less costly labor such as pharmacy technicians. The objectives of this study were to describe hiring trends for both the pharmacist and technician workforces in licensed pharmacies on a biennial basis from 2006 through 2020 using data collected in Minnesota. Ecological comparisons were made between the survey years using descriptive statistics. For open-ended questions added to the 2020 survey, content analysis was applied. Demand for technicians increased which might be due to the expansion of their roles into activities that had been reserved for the pharmacist. Pharmacies reportedly would like to hire pharmacists to meet the demand for new services that pharmacists can provide. However, respondents articulated that this is not feasible under current economic pressures. This represents a lost opportunity for transformation in pharmacy that would establish pharmacists' roles in the rapidly transforming health care value chain. We conclude that hiring dynamics in pharmacies are being driven more by economic and organizational shifts than meeting the demand for services that pharmacists can provide.

Background: The Medicare Prescription Drug Improvement and Modernization Act of 2003 provides outpatient prescription drug coverage for Medicare beneficiaries through private insurers. This coverage is available through 2 primary venues: stand-alone prescription drug plans (PDPs) and integrated managed care (or Medicare Advantage) plans that also provide prescription drug coverage (MA-PDs)., Objectives: The first objective was to describe factors associated with Medicare beneficiaries choosing to enroll in any Medicare part D PDP. The second objective was to describe factors associated with the choice of an MA-PD, given enrollment in the part D program., Methods: The study used a cross-sectional, survey design. Data were collected from a stratified random sample of 5000 community-dwelling adults, aged 65 years and older in the Center for Medicaid and Medicare Services Region 25. Data were collected by means of a mailed questionnaire. Data analyses included univariate and bivariate descriptive statistics and multivariate probit modeling., Results: The overall adjusted response rate was 50.2% (2309 of 4603). Data from 1490 respondents (32.4% of those attempted) were analyzed in this study. Nearly 75% of sample members elected to enroll in one of the Medicare part D coverage options in 2007, with more than 3 times as many choosing a PDP compared with a MA-PD option (57.2% vs 17.8%). A variety of variables including rurality, plan price, perceived future need for medications, and preferences emerged as important predictors of choosing to enroll in any Medicare part D drug plan, whereas rurality, state of residence, and number of diagnosed medical conditions were associated with the decision to enroll in a MA-PD., Conclusions: Models of health insurance demand and plan choice applied in this context appear to be modestly effective. Rurality and state of residence were particularly important contributors to both of these decisions, as were a variety of individual characteristics., (Copyright 2010 Elsevier Inc. All rights reserved.)

Background: Typically, patients are unaware of the cost consequences regarding prescribing decisions during their clinical encounter and rarely talk with their physicians about costs of prescription drugs. Prescription medications that are deemed by patients to be too costly when the costs become known after purchase are discontinued or used at suboptimal doses compared to prescription medications that are deemed to be worth the cost., Objectives: To learn more about the prescription choice process from several viewpoints, the purpose of this study was to uncover and describe how patients, prescribers, experts, and patient advocates view the prescription choice process., Methods: Data were collected via 9 focus group interviews held between April 24 and July 31, 2007 (3 with patients, 3 with prescribers, 2 with experts, and 1 with patient advocates). The interviews were audiotaped and transcribed. The resulting text was analyzed in a descriptive and interpretive manner. Theme extraction was based on convergence and external divergence; that is, identified themes were internally consistent but distinct from one and another. To ensure quality and credibility of analysis, multiple analysts and multiple methods were used to provide a quality check on selective perception and blind interpretive bias that could occur through a single person doing all of the analysis or through employment of a single method., Results: The findings revealed 5 overall themes related to the prescription choice process: (1) information, (2) relationship, (3) patient variation, (4) practitioner variation, and (5) role expectations. The results showed that patients, prescribers, experts, and patient advocates viewed the themes within differing contexts., Conclusions: It appears that the prescription choice process entails an interplay among information, relationship, patient variation, practitioner variation, and role expectations, with each viewed within different contexts by individuals engaged in such decision making.

Complexity of medication regimens in community dwelling elders is examined in relationship to emergent care use, hospitalization and self management of medications in this secondary data analysis of OASIS data and medication data from all 2004 open admissions to 15 home health care agencies. Preliminary findings and the use of innovative techniques are discussed highlighting the predictive potential for medication complexity in other settings, risk stratification, and design implications for both clinical tools and databases.

Objectives: To describe PharmD students' work experiences and activities; examine their attitudes towards their work; examine perceptions of preceptor pharmacists they worked with; and determine important issues associated with career preference., Methods: A written survey was administered to third-year doctor of pharmacy (PharmD) students at 8 colleges and schools of pharmacy in the Midwest., Results: Five hundred thirty-three students (response rate = 70.4%) completed the survey instrument. Nearly 100% of PharmD students reported working in a pharmacy by the time their advanced pharmacy practice experiences (APPEs) began. Seventy-eight percent reported working in a community pharmacy, and 67% had worked in a chain community pharmacy. For all practice settings, students reported spending 69% of their time on activities such as compounding, dispensing, and distribution of drug products., Conclusions: Most students are working in community pharmacy (mainly chain) positions where their primary function is traditional drug product dispensing and distribution. Having a controllable work schedule was the variable most strongly associated with career choice for all students.

Background: Effective treatment for chronic diseases often requires medication refill persistence. Health plans have frequently increased the amount of member cost-sharing by implementing tier-copayment pharmacy benefit designs and raising copayments. However, increased member costshare may present a barrier to the management of chronic conditions. Little is known about the relationship between the magnitude of member cost-sharing and antihypertensive persistence among members newly initiating therapy., Objective: To investigate and quantify the relationship between amount of prescription cost-sharing and medication refill persistence among members newly initiating therapy with a single-agent angiotensin system blocker--either an angiotensin-converting enzyme inhibitor (ACEI) or angiotensin II receptor blocker (ARB)., Methods: This was an observational cohort study of pharmacy and medical claims data for 29 employers with approximately 310,000 beneficiaries that did not have a change in pharmacy benefits including the amount of member cost-share in 2004. The claims data were supplemented with census data for household income and race at the Zip Code level. Selected patients were new users of single-agent ACEIs or ARBs (i.e., excluding ACEI or ARB in combination with hydrochlorothiazide or amlopdipine) between January 1 and June 30, 2004, without a pharmacy claim for an ACEI or an ARB in the 6 months prior to the index claim for either drug type. Medication refill persistence was measured in 3 ways: (1) total number of days without ACEIs or ARBs during 6 months follow-up, (2) proportion of days covered (PDC) with less than 80% defined as nonpersistent during 6 months follow-up, and (3) number of days to the first gap of more than 30 days in medication coverage from the index date to end of 2004 (mean [SD] follow-up=9.2 [1.8] months). Three statistical models were fit: Tobit model, examining the association between cost-sharing and total number of medication gap days; logistic regression, testing the association between cost-sharing and odds of being nonpersistent; and Cox proportional hazards model, assessing the association between cost-sharing and time to a 30-day gap., Results: Among the eligible population, a study cohort of 1,351 members newly initiating a single-agent ACEI or ARB was identified. These members were 41.8% female and had a mean age of 55.9 (SD=13.1) years. On average, their member cost-share was $12.42 (SD=$8.50) per 30-day supply. Each $1 increment in per 30-day cost-share was associated with a 1.9% increase in total gap (beta=0.019, 95% confidence interval [CI], 0.007-0.030, P=0.001), a 2.8% increase in the odds of being nonpersistent (odds ratio [OR]=1.028, 95% CI,1.011-1.045, P=0.001), and a 1.0% increase in the risk of having a gap of more than 30 days (hazard ratio [HR]=1.010, 95% CI, 1.001-1.019, P=0.034). Following transformation of the cost-sharing coefficient in each model, a $10 increment in cost-share had a consistent negative influence; 18.9% greater total gap days (beta=0.189, 95% CI, 0.073-0.304), 31.9% greater odds of being nonpersistent (OR=1.319, 95% CI, 1.120-1.553), and 10.2% larger hazard of having a gap of more than 30 days (HR=1.102, 95% CI, 1.007-1.205)., Conclusion: For members newly initiating single-agent angiotensin system blocking medication, the amount of prescription cost-sharing was associated with a negative impact on refill persistence.

Background: Health insurance instability (ie, temporal gaps in health insurance coverage) is a prevalent phenomenon in the United States. To date, most studies have focused on the factors that affect the intermittent lack of health insurance coverage. However, no studies known to the authors have examined the factors associated with prescription drug insurance instability (ie, temporal gaps in drug insurance coverage) among working-age adults. Developing an accurate profile of persons with unstable drug insurance is essential to formulate rational policy to address this problem., Objectives: The objectives of this study were to (1) document the prevalence of prescription insurance instability among working-age adults and (2) describe the association between prescription drug insurance instability and demographic, socioeconomic status, and employment characteristics., Methods: The data source used in this study was the 2000 Medical Expenditure Panel Survey. This study used a cross-sectional design using data provided by respondents at each of the 3 interviews conducted during the year 2000. Chi-square and hierarchical multinomial logistic regression analyses were used to describe the associations among (1) demographics, (2) socioeconomic status, and (3) employment characteristics and drug insurance status (classified as continuous, absent, or unstable)., Results: During the year 2000, 12.5% (21.1 million) of the working-age adults in the United States had unstable prescription drug coverage. Persons aged 35-54 years had lower rates of drug insurance instability compared with those aged 18-24 [adjusted odds ratio 0.66 (95% confidence interval 0.54-0.80)]. The least educated (12 or fewer years of education) were more likely than those with more education (13-16 years) to experience at least one period without drug coverage (62% vs 32%, P<0.01). The poorest respondents (those at less than 200% of the federal poverty level) were more likely than the wealthiest respondents (those at more than 400% of the poverty level) to report at least some time without drug coverage (37% vs 28%, P<0.01). Those experiencing a divorce or death of a spouse were more than twice as likely as stably married persons to experience at least one period without drug insurance [adjusted odds ratio 2.23 (95% confidence interval 1.68-2.96)]. Adults who were unstably employed during the year and/or who worked for small firms generally experienced higher rates of drug insurance instability., Conclusions: Prescription drug insurance instability is a prevalent phenomenon among working-age adults in the United States, with approximately 1 in 8 experiencing this problem during 2000. Our results suggest that demographics, socioeconomic status, and employment characteristics all play important roles in predicting prescription drug insurance status, with the least educated and poorest being particularly vulnerable to interruptions in drug coverage. Premium assistance programs providing subsidies to small firms' low-income employees and permitting small firms to form insurance pools may help to decrease the number of drug coverage uninsurance spells in this population.

Background: It has been demonstrated that collaborative drug therapy management may result in enhanced medication adherence and improved clinical outcomes. It is not yet known whether CDTM is associated with patients' perceptions of care or self-reports of health-related quality of life., Objectives: Examine the impact of collaborative drug therapy management (CDTM) on patients' perceptions of care and health-related quality of life in 15 ambulatory clinics (6 intervention, 9 comparison) in the Fairview system of Minneapolis-St Paul, Minn., Methods: The intervention was medication therapy management provided by pharmacists in collaboration with physicians (CDTM) for a 12-month period. Subjects were selected by age, gender, and presence of one of 12 medical conditions in the intervention (n=285) and comparison (n=285) group of patients. Comparison patients received usual care while intervention patients received at least 2 CDTM encounters. The CAHPS (formerly called the Consumer Assessment of Health Plans) 2.0 survey was administered to both the intervention and comparison groups poststudy to analyze patients' perceptions of care. The Short Form-12 (SF-12v2) was administered to intervention group patients pre-CDTM and 6 months post-CDTM to measure health-related quality of life in the intervention group., Results: Differences in CAHPS scores were not statistically significant (P>.05), although there was a trend toward higher ratings of patients' personal doctor/nurse and doctors' communication in the CDTM intervention group relative to the comparison group. Physical role, social functioning, and physical component summary scales of the SF-12v2 improved significantly (P=.001, P=.014, and P=.024, respectively; P< or =.025 level)., Conclusions: A trend toward improvements in patient perceptions of effectiveness of care using CAHPS suggests a need for further study. Health-related quality of life improvements in this study meet or exceed previous results incorporating pharmacists into primary care. Intensity and integration of CDTM services may be an explanation; however, prepost study design limits inferences.

Background: Previous research on the impact of various cost-sharing strategies on prescription drug use has not considered the impact of direct-to-consumer (DTC) advertising., Objective: To explore the association of cost-containment strategies with prescription drug use and to determine if the association is moderated by DTC prescription drug advertising., Methods: The study population included 288 280 employees and dependents aged 18 to 65 years with employer-sponsored health insurance contributing to the MEDSTAT MarketScan administrative data set. Person-level enrollment and claims data were obtained for beneficiaries enrolled continuously during July 1997 through December 1998. Direct-to-consumer advertising data were obtained from Competitive Media Reporting and linked to the MEDSTAT enrollment files. Localized DTC advertising expenditures for one class of medication were evaluated and matched with prescription claims for eligible MEDSTAT contributors. The association of various types and levels of cost-sharing incentives with incident product use was evaluated, controlling for the level of DTC advertising, health status, and other demographic covariates., Results: The relationship of cost-sharing amounts with drug use was modified by the level of DTC advertising in a geographic market. This relationship was dependent on the type of cost-sharing, distinguishing between co-payments for provider visits and co-payments for prescription drugs. Compared with low-advertising markets, individuals residing in markets with high levels of advertising and paying provider co-payments of $10.00 or more were more likely to use the advertised product. In the same markets, higher prescription drug co-payments were associated with a decreased likelihood of using the advertised product. A similar relationship was not observed for the nonadvertised competitor., Conclusions: Among insured individuals, response to cost-sharing strategies is moderated by DTC prescription drug advertising. The relative ability of cost-sharing strategies to influence drug use should be interpreted with caution in the presence of DTC advertising.

This Issue Brief reports on changes in manufacturers' prescription drug prices during the first three months of 2004 (January through March) for the brand name prescription drugs most widely used by Americans age 50 and over. This report is the first quarterly update in an ongoing study of changes in drug manufacturer prices-that is, manufacturers' prices charged for drugs they sold to wholesalers. A baseline study published in May 2004 by the AARP Public Policy Institute identified steady increases in the average annual manufacturer price from calendar year 2000 through calendar year 2003. This report's focus is on changes in the prices that brand name drug manufacturers charge to wholesalers for sales to retail pharmacies. The manufacturer's charge to wholesalers is the most substantial component of a prescription drug's retail price. When there is an increase in the manufacturer price to wholesalers for a brand name drug, this added cost is generally passed on as a similar percent change in the retail price to most prescription purchasers. The report presents three measures of price change (see methodological appendix). The first set of findings are annual rates of change in manufacturers' prices for widely used brand name drugs, using both rolling average and point-to-point estimates; information is presented on percentage change in manufacturer price and on potential dollar changes in consumer spending. The second set of findings are three-month percentage changes in prices (i.e., changes from December 31, 2003 through March 31, 2004); the distribution of percentage price changes is shown, as well as differences in average percentage price changes by manufacturer and by therapeutic category.

Background: Collaboration between physicians and pharmacists is one approach to address drug-related morbidity and achieve therapeutic goals. A collaborative practice of pharmaceutical care has been used in the Fairview Clinics System of Minneapolis-St Paul since 1999., Methods: The quality of therapeutic determinations made by pharmacists within this collaborative practice of pharmaceutical care was studied by a 12-member panel of physicians and pharmacists who used randomly selected patient records. This was a quality improvement and care process validation component of a study evaluating the effects of drug therapy management in patients receiving prepaid medical assistance. An implicit review process was used to evaluate the clinical credibility of therapeutic determinations made by pharmaceutical care practitioners., Results: A total of 5780 drug therapy problems were resolved for 2524 patients receiving pharmaceutical care. The rate of therapeutic goals achieved increased from 74% at the time of patients' initial pharmaceutical care encounters to 89% at patients' latest encounters. In this quality assessment analysis panel members performed a total of 4779 evaluations of clinical decisions. Panelists indicated agreement with the evaluations in 94.2% of cases, expressed a neutral opinion in 3.6% of cases, and disagreed in 2.2% of cases. Intraclass correlation coefficients ranged from 0.73 to 0.85., Conclusions: The decisions made by pharmaceutical care practitioners working in collaboration with physicians to provide drug therapy management services are clinically credible based on the evaluations and comments of a peer review panel. This study provides information on the quality of care provided by pharmacists when collaborating with physicians to provide drug therapy management services.

Objectives: This study examined the impact of drug coverage generosity on older persons' prescription events (fills) and expenditures., Methods: A cross-sectional study was conducted of 6237 older persons from the 1995 Medicare Current Beneficiary Survey. Dependent variables were per capita prescription events and expenditures. Independent variables were insurance type and drug coverage generosity. Control variables included sociodemographic and health status factors., Results: Regardless of insurance type, per capita prescription events increased as drug coverage generosity improved and then decreased at the most generous level. Per capita prescription expenditures increased as generosity improved; with generous prescription coverage, prescription expenditures were approximately 3 times those with Medicare only., Conclusions: Even when factors that affect drug use and insurance selection are controlled, prescription coverage generosity influences prescription use.

Interventions performed by 89 community pharmacists in 5 states to correct the prescribing problems they identified on new prescription orders were documented by trained observers. Pharmacists intervened to resolve a prescribing-related problem in 623 (1.9%) of 33,011 new prescription orders that were screened and dispensed during the study period. A panel of three expert evaluators concluded that 28.3% of the prescribing problems identified during the study could have caused patient harm if the pharmacist had not intervened to correct the problem. The rate at which pharmacists identified prescribing problems was negatively related to the number of prescriptions they dispensed per hour, suggesting that in pursuing distributive efficiency, some pharmacists may be exceeding their safe dispensing threshold. The authors recommend that the interprofessional system of oversight and verification (i.e., "checks and balances") in the delivery of pharmaceutical care in the community setting should be maintained and strengthened.

For several years, the American Society of Hospital Pharmacists (ASHP) has voiced concern about the impact of federally mandated changes on the pharmaceutical products marketplace. Since this marketplace is relatively inelastic, manipulating one segment in the interest of cost efficiencies is likely to result in price increases in other segments. That manipulation could come through such decisions as a "one-price" policy for pharmaceuticals, mandatory rebates for certain segments of the marketplace, or the elimination of discounts. The issue of cost-effective purchasing of prescription drugs and related supplies has recently come under increased scrutiny from the U.S. Congress, the Department of Health and Human Services, the General Accounting Office, and the Federal Trade Commission. In light of these and future activities, ASHP determined that there was a need to collect credible data on the potential impact of the termination of the Robinson-Patman Act's nonprofit institutional exemption, other discounts, or both on pharmaceutical expenditures in institutional health-care settings. The authors of this paper report the results and analysis of a 1990 mail survey conducted by ASHP and Concepts in Healthcare, Inc., to collect information on pharmaceutical purchasing and discounting procedures in community hospitals and selected nonhospital settings in the United States. Survey respondents reported that they would expect substantial increases in pharmaceutical expenditures if volume and nonprofit discounts were eliminated. Nonprofit hospitals expected a 24.4% increase in pharmaceutical expenditures in the wake of discount elimination, while for-profit institutions projected an 11.9% increase. Pharmaceutical expenditures of the study hospitals averaged $1.69 million per year; respondents estimated that this sum would increase by $390,000 (23.1%) if volume and nonprofit discounts were eliminated.

Several major trends were observed in these findings from the 1990-91 National Pharmacists' Compensation Survey (for details see the final report). Only 72.6% of licensed pharmacists were working full-time in pharmacy; another 14.4% were working part-time in pharmacy, and nearly 13.0% were either not working in pharmacy or not working at all. Although 90.0% of active men pharmacists were working full-time, only 70.7% of active women pharmacists were working full-time. Men were more likely to be working in independent and chain pharmacies as a manager or owner. Women were more likely to be working in hospital or chain pharmacies as a staff pharmacist. Pharmacists' base salary in 1990 was substantially higher for men than for women with averages of $46,661 versus $42,668. Total pharmacy compensation showed a similar pattern but an even greater spread between men and women with averages of $51,032 versus $44,751. However, after adjusting for years in practice and number of hours worked per week, the base HWE for employee pharmacists shows that men and women pharmacists do get "equal pay for equal work" in the first 20 years of practice. The difference that develops between men and women with more years in practice is probably due to the higher proportion of men in management positions and to differences in practice setting preferences.(ABSTRACT TRUNCATED AT 250 WORDS)

Twenty-seven patients with indwelling urinary catheters and chronic bacteriuria were studied for methenamine efficacy. In a crossover fashion, each patient received methenamine mandelate granules 4 g/day alone, with ascorbic acid 4 g/day, and with ascorbic acid 4 g/day plus cranberry cocktail one 1/day. Proteus vulgaris, Pseudomonas aeruginosa, and E. coli were the common pathogens. Urinary acidifiers had no significant effect on mean urine pH, however, high urinary formaldehyde concentrations were associated with the use of ascorbic acid. Bacteriocidal formaldehyde levels were more frequently present in patients with acidic urine pH than those with alkaline pH. Although ascorbic acid increased formaldehyde levels, additional cranberry cocktail had no further effect. Despite higher formaldehyde levels, urine culture results were positive in most cases with or without urine acidification. Methenamine therapy may be of limited value in asymptomatic chronic bacteriuric patients with indwelling catheters.

The future holds great promise for the Rx-to-OTC switch, if we will collectively plan and manage that process. The impact of Rx-to-OTC switches will extend far beyond the technical and regulatory issues and implications. Certainly, pharmaceutical manufacturers, the Food and Drug Administration, and the Federal Trade Commission are at the center of this issue, but no less important are the roles of physicians, pharmacists, and consumers. The social and economical, and even logistical, aspects of the switch process should be considered as antecedents to an Rx-to-OTC switch policy, rather than as consequences to be measured after such a policy has been determined. Finally, the evolution of an Rx-to-OTC switch policy in the coming months and years should avoid the path of political and administrative expediency and it should avoid the consideration of special interests in isolation from the broader social context. The development of a sound Rx-to-OTC switch policy will occur only if the direction and demand truly comes from within the ranks of the consumers.

Consumers increasingly want to be informed about the processes involved in their own health care. Health professionals may be called upon to recommend appropriate consumer-oriented sources of information. To assist the health professional in making a rational recommendation, 15 currently available consumer-oriented books on prescription medications were compared with respect to readability, number of drugs covered, completeness of drug monograph information, price, and other factors. Mean readability scores, reported as a reading grade level, ranged from 9.2 to 14.3. The number of drugs covered by these books ranged from 135 to 1,200. Monograph completeness scores were assigned by determining the percentage of information from a standard reference's drug monograph covered in each book. The lowest percentage completeness score was 21.4%, while the highest was 76.7%. Prices for the books ranged from $2.50 to $19.95. Regardless of the relative priorities placed on these factors, a consumer or health professional may use the objective and descriptive assessments of this study to make an informed decision when choosing among consumer-oriented sources of medication information.

The clinical effectiveness of albuterol, isoetharine, and metaproterenol administered by aerosol inhalation at manufacturer-recommended doses was compared. A double-blind, placebo-controlled, crossover comparison of albuterol 280 micrograms, isoetharine 680 micrograms, and metaproterenol 1300 micrograms was conducted in 10 adult men with reversible, chronic pulmonary obstruction. FEV1 (forced expiratory volume at one second), FEF25-75 (forced expiratory flow rate from 25 to 75% of vital capacity), and FVC (forced vital capacity) were determined periodically for six hours after drug administration. Bronchodilator effects, adverse effects, and cost of treatments were compared. Theophylline therapy was unaltered during the study, and serum theophylline concentration was determined periodically to control for its effect on pulmonary function. Serum theophylline concentration was not used as a covariate since it resulted in minimal change in the pulmonary-function measures. The mean maximum percent change from baseline for FEV1 for each drug was superior to placebo; there were no differences among drugs. Comparing area under the curve of mean percent change in FEV1 versus time, albuterol and metaproterenol produced changes that were greater than placebo but not different from each other or isoetharine. For FEF25-75 and FVC, albuterol and metaproterenol, respectively, were superior. No pattern of adverse effects was identifiable among the four treatments. The average wholesale cost of albuterol products was approximately 1.7 times the cost of metaproterenol products. Under the conditions of this study, metaproterenol was superior to isoetharine and therapeutically equivalent to and less expensive than albuterol.

This article is intended to introduce the reader to the concepts of CEA/CBA for purposes of evaluating innovative pharmacy services. Furthermore, sensitization to the issues surrounding CEA/CBA studies should allow the reader to be more discriminating in reviewing such reports in the literature. Rising costs for health care and the existence of limited resources are forcing policy makers to allocate resources in ways that maximize return-on-investment. It is felt by some that in the 1980s, researchers will be expected to answer the questions, "How much better is the innovation?" and "How do the expected benefits of an innovation compare with the benefits that could be obtained if the resources were used in some alternative way?" Part of the solution will require changes in the training and practice of health professionals. Future physicians, pharmacists, and others will need to acquire skills from the behavioral, social, and decision sciences (e.g., epidemiology, statistics, economics, decision analysis). The notion of cost-effective clinical decision making needs to be taught at all levels. Health practitioners involved with decision making at the level of the patient need to become more knowledgeable of the overall impact (regarding costs and benefits) of their decisions. Finally, evaluation of innovative pharmacy services is but one element of a management program for clinical services. Our attempt is not to deemphasize the need for studies documenting the value of clinical services, but rather to put evaluation in perspective with an equally important need, the need for development of an overall pharmacy program that is not only cost effective but efficient as well. The means to this end is a total management program integrating all pharmacy services.

The relative importance of six switch evaluation criteria in pharmacists' evaluations of the appropriateness of switching four drugs from prescription to nonprescription status was assessed. A questionnaire was constructed for three potential switch candidates (metaproterenol, cimetidine, and nystatin) and one already switched drug (ibuprofen 200 mg). Pharmacists were asked to judge (1) the overall appropriateness of switching these four drugs and (2) the appropriateness of switching these drugs based on the FDA switch criteria of safety, effectiveness, and labeling and two other proposed criteria: the need for oral counseling about the product and perceived market need for the product. Additionally, pharmacists were asked to rate whether they believed the study drugs would be profitable to their pharmacies if the drugs were switched to nonprescription status. A total of 1161 pharmacists were reached by the mailings, of whom 417 (34.8%) responded. Only ibuprofen 200 mg received a positive overall switch approval rating from the pharmacists; cimetidine received the lowest rating. The six evaluation criteria were tested for significant association with pharmacists' overall judgment of the appropriateness of switching each drug. The three most influential criteria were safety, labeling, and market need for the product, respectively. Profitability to the pharmacy was not significantly associated with pharmacists' overall judgment of switch appropriateness. Regression analysis identified safety, labeling, and market need as important in the evaluation of all four drugs, and pharmacists' evaluation of the relative importance of these criteria was a predictor of their overall judgment of the appropriateness of a switch. Consumer safety, not personal economic interests, most influenced pharmacists' judgment of the appropriateness of a switch from prescription to nonprescription status for four drugs.

The formulation of a strategy for change in pharmacy practice is described. Pharmacy has focused more on improving efficiency for existing functions than on identifying and adapting to the changing needs of society. The survival of the profession will depend on its ability to meet the present and future needs of society. Structural and procedural aspects of strategy formulation should focus on building a consensus within the profession. Interests of professional leaders, educators, practitioners, and the public should be incorporated into the profession's strategy. A center for strategic planning, supported by national pharmacy organizations, is suggested. Formulation of a strategy for pharmacy should involve: (1) an assessment of health-care needs relevant to pharmacy; (2) comparative evaluations of methods for delivering needed services; (3) integration with other health-care services; (4) organization and management of pharmacy practice; (5) financing considerations; and (6) legislative and regulatory changes. Planned strategic change will provide pharmacy with a mechanism for channeling its future activity in a direction that can effectively and efficiently meet the needs of society.