Obtaining accurate patient‐specific perioperative anaesthetic costs in orthopaedic anaesthesia

□ The aim of the study was to obtain perioperative patient‐specific costs associated with orthopaedic anaesthesia □ A prospective observational study design was used to determine fixed, semi‐fixed, and variable costs □ The preliminary results of the first 60 patients reports a mean total perioperative anaesthetic cost of £291 (SD: £103.9, median: £278.09, IQR: £219.3–£369.5) □ Fixed and semi‐fixed costs are a major cost component of anaesthesia; variable costs account for only 12 per cent of total cost □ The results of this study will be used in an economic evaluation examining the use of different anaesthetic techniques in orthopaedics     

The health of elderly residents in long term care institutions in New Zealand

AIMS: To estimate the morbidity of residents in long term care institutions in Hamilton, New Zealand and examine the prescribing practice within these institutions. METHODS: One hundred residents were selected at random from the total population of residents in long-term institutions in Hamilton. Residents were examined by a physician to arrive at ICD-9 diagnoses and details were recorded about prescribing practice. RESULTS: Eighty residents were examined. Of these, 73% had dementia. Forty-five per cent were diagnosed as having heart failure and 44% cerebrovascular disease. The most common previously undiagnosed disorder was postural hypotension (24%). Residents were prescribed an average of 4.5 non-psychotropic medications. Seventy-seven per cent of residents were prescribed three or more medications. CONCLUSION: Elderly residents in long term care institutions in Hamilton have complex health care needs which offer particular challenges for doctors and other health care workers. Regular health care reviews could lead to more accurate diagnosis and better prescribing practice.     

Changes in primary care prescribing in the northern region UK: 1989–1992

Prescribing rates for the Family Health Service Authorities (FHSAs) of the Northern region were studied for the period June 1989–September 1992. Over three years the total number of items prescribed in the region rose by 13 per cent, and costs rose by 39 per cent. Trends within individual leading British National Formulary (BNF) chapters were different. The number of endocrine items increased substantially faster than average (45 per cent, over three years); gastro-intestinal (GI) items also showed an above average rise; central nervous system (CNS) and infections items rose by only 6–8 per cent. In terms of cost, there were major rises for both endocrine (89 per cent) and CNS (62 per cent) drugs, but musculoskeletal (MS) prescribing costs were nearly static (+5 per cent). These trends were similar across the nine FHSAs in the Northern region. Significant upturns in the prescribing trends for CNS and endocrine drugs occurred in early 1992 leading to the high overall increases already noted. Despite the pressure for conformity associated with changes in the funding of general practitioners' prescribing budgets, the differences between FHSAs in their absolute prescribing rates have largely remained. Within each therapeutic group the rankings of FHSAs have also shown surprising consistency. Whether these observations are attributable to fundamental differences in patient populations, or merely the consequence of inertia with respect to historic rates, is debatable. The reasons can only be properly determined by focused investigation of data linking prescribing and patient demographics.     

Laxative prescribing during pregnancy in primary care

□ Hormonal changes, mechanical pressure and concurrent medication all contribute to altered bowel habit during pregnancy □ It has been suggested that pregnant women are more likely to receive laxatives than the baseline population □ A retrospective case control study using a primary care prescribing database was undertaken to compare laxative prescribing before and during pregnancy with that in matched controls □ Prescribing rate of laxatives increased during pregnancy compared with before becoming pregnant but this was not different to controls □ Pregnant women were more likely to receive a laxative if they were using antibacterials, preparations for haemorrhoids or drugs for nausea and vertigo.     

Implementation of statin prescribing guidelines: a cost effectiveness analysis

□ The evidence that statins reduce coronary heart disease mortality and morbidity is strong yet these drugs are under‐utilised in the UK □ Statin prescribing guidelines were implemented in five general medical practices using academic detailing, audit, feedback and written materials □ Statin prescribing increased following introduction of the guidelines, to a greater extent than predicted by regression analysis in the absence of intervention, with an additional 102 patients being treated 12 months after intervention □ Assuming benefits in this patient group are equivalent to those seen in the major trials, this equates to an additional 3.6 major coronary events and 1.5 coronary deaths prevented □ Including both the cost of guideline introduction and the additional statin drug costs, the cost per event prevented was 28,063 for major coronary events and £67,351 for coronary deaths.     

Poor correlation between predicted ideal and prescribed digoxin dose: a community‐based pharmacokinetic study in the elderly

□ This study assessed if population‐based pharmacokinetics predicted measured plasma digoxin concentrations in elderly community‐managed patients □ Twenty‐seven per cent of the sample showed plasma concentrations consistent with a therapeutic level over an entire 24‐hour dosing schedule; 36 per cent showed therapeutic levels for at least some of the dosing schedule; the remainder showed digoxin concentrations not consistent with achieving a therapeutic plasma concentration for any part of the dosing schedule □ The mean daily prescribed dose of digoxin was significantly lower than that predicted from population kinetics.     

SIGN guidelines and the management of sore throat in community pharmacy

□ Scottish Intercollegiate Guidelines Network guidance on the management of sore throat recommends analgesia and refer to the role of the community pharmacist in advising symptomatic relief □ Advice given to 749 patients from 65 community pharmacies; 49 patients (6.5 per cent) were referred to their general practitioner □ Paracetamol, drug of choice from SIGN guideline, was recommended to 219 patients (29 per cent); a preparation for symptomatic relief either alone or in combination with an analgesic was advised for 590 patients (79 per cent) and of these, 315 patients (42 per cent) were recommended lozenges with anaesthetic and antibacterial action □ Compliance with SIGN guidelines was observed regarding choice of analgesic □ Evidence is required for choice of symptomatic relief.     

A randomised,controlled study to quantify the benefits of community pharmacist interventions on the prescribing of cardiovascular drugs in general practice

□ The impact of a one‐off medication review by a specially trained community pharmacist, with recommendations to the patient's general practitioner was studied □ No differences were observed in any of the physiological or biochemical monitoring indicators □ There was greater improvement post‐intervention in some key quality prescribing indicators (eg, prescribing of antiplatelet and beta blocker or ACE inhibitor post‐MI); others showed equal improvement in both groups (diabetic patients on ACE inhibitor) □ A single review of medication records by a practice‐based pharmacist, with a dependence on the general practitioner to implement change may have limited benefit.     

Excretion of digoxin and its metabolites in urine after a single oral dose in healthy subjects

The 3-day urinary excretion of digoxin, its conjugated and unconjugated hydrolytic metabolites and dihydrodigoxin, was studied in 8 healthy men after oral administration of tritiated digoxin. Analysis was performed by high pressure liquid chromatography (HPLC). The total radioactivity corresponded to 45.4±2.0 per cent (mean ± S.E.M.) of the dose. By HPLC 424 ± 2.7 per cent was recovered before and 44.0 ± 2.7 per cent after deconjugation of the samples. Digoxin and dihydrodigoxin constituted 40.3 ± 2.9 per cent; of this 0.7 ± 0.4 per cent was dihydrodigoxin. The sum of the hydrolytic metabolites was 2.1 ± 0.3 per cent before and 3.4± 0.5 per cent after deconjugation. No correlation was found between gastric pH and the production of hydrolytic metabolites. The relative amount of these metabolites was maximal (mean 13.4 per cent of the excretion) in the 4.8 h sampling period. During the first 8 h an average of 8.6 per cent of the radioactivity was not recovered by HPLC. The metabolism of digoxin as judged by urinary excretion was limited and showed great variation during the early hours after treatment. The excretion of unchanged digoxin in some individuals constituted as little as 60 per cent over the first 12 h after dosing.     

Headache experiences and medication use in primary care

□ A survey was used to examine headache experiences and medication use in an adult population sample □ Seventy per cent had experienced headaches in the previous three months □ Sixty per cent had taken medication for headache in the past three months □ Most headache sufferers self‐treated their headaches □ Only a few respondents had taken medication before headache pain started or had found their medication ineffective, but combination therapy was common.     

Gender and age influences on prescription and consultation frequency for multiple sclerosis patients

□ The study aimed to examine whether gender and age affects the burden of disease in secondary care in terms of number of prescribed drugs and number of consultations with the general practitioner (GP) for multiple sclerosis and control patients □ Anonymised data for 1996 was obtained for all patients (patient years at risk = 220,538) from 24 GP practices in the GP Morbidity Database who had a Read code of MS at some point from 1993 to 1996 and a randomly selected age, gender and surgery matched control group □ A total of 216 cases was identified, giving a prevalence of 97.9 per 105 (based on patient years at risk in the database for 1996; n=220,538). Sixty‐seven per cent (145/216) of cases were female. The mean age was 46.7 (range 17 to 84 years) □ Gender differences for the MS patients, but not controls were found. For example, although females in both the control and MS population had significantly more consultations than the corresponding males, only the control females had more items prescribed than control males (p=0.033) □ This study warrants further work to elucidate whether specific therapeutic areas or MS‐treated symptoms are influenced by gender     

Cross-sectoral pharmacotherapeutic coherence in the Netherlands

Objectives — To measure the extent of pharmacotherapeutic coherence across sectors of Dutch health care from the hospitals' perspective, and to identify perceived markers of coherence and barriers to improvement Methods — Telephone interviews were carried out with hospital pharmacists (76), community pharmacists (5), and clinical pharmacologists (9) affiliated to pharmacies serving 120 Dutch general hospitals. Coherence between (a) hospital and general practice, (b) hospital and nursing home practice, (c) hospitals, and (d) hospital inpatient and outpatient practice was reported and assessed against a set of indicators Results — Almost all hospitals (93 per cent) had formulary agreements or prescribing policies in place and 86 per cent of these had a printed hospital drug formulary (HDF). Over 50 per cent of hospitals reported that they had established coherence with nursing home practice and/or with other hospitals. Less than half of the hospitals had established coherence with general practice. Few hospitals reported activities to review outpatient prescribing and its implications for follow-on prescribing in primary care. Reported barriers to increasing coherence could be classed into three categories: economic, organisational and social. Suggestions to enhance coherence included influencing professionals' practice through training, and greater use of regional and national policies on prescribing Conclusion — Therapeutic coherence within Dutch health care is far from ideal. The discrepancy between the actual and desired extent of coherence arises from organisational and economic barriers. To date, activities in this area have relied on professional proactivity rather than a structured approach. To move forward, (dis)incentives should be created for health care providers and professionals across all sectors, including pharmacists and prescribers     

Determinants of drug utilization in an elderly population in North and West Belfast

This study was designed to survey drug prescribing for all patients over 65 years in institutional and hospital care in North and West Belfast, together with a home-based sample, and to determine the influence of age, sex, mental score, functional score and place of abode on prescribing habits. Multiple regression analysis was used to analyse the effects of the various parameters on number of drugs received. Drugs were categorized into therapeutic classes and for each class a separate logistic regression analysis was performed to identify the variables which independently predicted receipt of that class. A total of 1094 people were surveyed with an average of 3.26 medications per person. The most common classes of drugs received were diuretics (39.8 per cent), analgesics (31.7 per cent), hypnotics (25.3 per cent), phenothiazines (21.7 per cent) and laxatives (20.9 per cent). Number of drugs received was not predicted by age or sex but by institutional or hospital placement. Placement was also the most significant independent predictor of drug class. Age, sex, mental and functional scores were less significant. Drug utilization in this representative elderly population seemed appropriate with low prescribing rates for some drug classes considered hazardous or ineffective in this age group.     

Integrating the community pharmacist into the diabetes team: evaluation of a new care model for patients with Type 2 diabetes mellitus

□ Diabetes is a major public health issue affecting 3 per cent of the population □ Integration of the pharmacist into the multidisciplinary care of patients with chronic conditions is supported by the profession and the government □ Community pharmacists engaging with their established customers and access to relevant data can, through use of a systematic process, identify the pharmaceutical needs of this patient group □ The model of care proposed is feasible in a primary care setting, resulting in acceptance of pharmaceutical care issues general practitioners and an improvement in patient care