Changing health-care systems

Many governments are encouraging competition for resources between health centres in an attempt to reduce costs and improve the quality of services. However, opponents to managed care believe that this will create more administrative costs and reduce patient choice. So-called purchasing organizations are being established to direct patients to the most cost-effective care. Assessing performance is complicated as very sick or difficult-to-treat patients are likely to be more costly. Statistical techniques can be used to clarify the impact of risk factors, such as smoking, on the outcome of care.     

Research priorities in pharmacokinetics

An opinion is expressed on the past, present and future roles of pharmacokinetic-pharmacodynamic research in the context of UK clinical pharmacology. On the basis of its current constitution, it seems unlikely that this area of research will be driven from within academic clinical pharmacology in the UK. Therefore, in order to bring its expertise and experience to bear effectively on the evolving emphasis on translational medicine and modelling and simulation, this community would need to reach out beyond its current preoccupations to increase interactions with the next generation of pharmacokineticists and pharmacometricians.     

Vaccination priorities

Selection of immunizations should be based on requirements and on risk of infection. According to the International Health Regulations, many countries require yellow fever vaccination and proof thereof as the International Certificate of vaccination. Additionally selected countries require proof of vaccination against cholera and meningococcal disease. A consultation for travel health advice is always an opportunity to ascertain that routine immunizations have been performed. Recommended immunizations often are more important for traveller's health than the required or routine ones. The most frequent vaccine preventable infection in non-immune travellers to developing countries is hepatitis A with an average incidence rate of 0.3% per month; in high risk backpackers or foreign-aid-volunteers this rate is 2.0%. Many immunizations are recommended for special risk groups only: there is a growing tendency in many countries to immunize all young travellers to developing countries against hepatitis B, as it is uncertain who will voluntarily or involuntarily get exposed. The attack rate of influenza in intercontinental travel is estimated to be 1%. Immunity against poliomyelitis remains essential for travel to Africa and parts of Asia. Many of the 0.2-0.4% who experience an animal bite are at risk of rabies. Typhoid fever is diagnosed with an incidence rate of 0.03% per month among travellers to the Indian subcontinent, North and West Africa (except Tunisia), and Peru, elsewhere this rate is 10-fold lower. Meningococcal disease, Japanese encephalitis, cholera and tuberculosis have been reported in travellers, but these infections are rare in this population. Although no travel health vaccine is cost beneficial, most professionals will offer protection against the frequent risks, while most would find it ridiculous to use all available vaccines in every traveller. It is essentially an arbitrary decision made on the risk level one wishes to recommend protection--but the priorities need to be set correctly.     

Pharmacokinetic monitoring in the community health-care setting

Ambulatory care pharmacokinetic profiling has been utilized with increasing frequency over the last decade. The demonstration of need is the first step in initiating outpatient pharmacokinetic service. This article identifies methods used in demonstrating a need and discusses the normal daily activities of an ambulatory pharmacokinetic service located in a university-based family medicine clinic. The reader will also learn of trends that ambulatory care pharmacokinetic programs will become involved with in the near future.     

Antidiabetic Drug Utilization in Hungary

Objective: To evaluate the utilization trends of antidiabetics in Hungary.Method: The analysis includes the drugs of antidiabetic therapy which were registered between 1998 and 2002 in Hungary. The consumption of antidiabetic drugs was analyzed by the ATC/Defined Daily Dose (DDD) method. The data used in this study were derived from the National Health Insurance and from MIS Consulting Company.Results: Between 1998 and 2002, the total consumption of antidiabetics increased by 41.8%, and reached 47.59 DDD/1000 inhabitants/day in 2002. The consumption of oral antidiabetics (OAD) increased by 33.41% (33.86 DDD/1000 inhabitants/d ay in 2002), while in the case of insulin the increase was 67.8% (13.74 DDD/1000 inhabitants/day). Sulphonylureas were the most frequently used class (21.11 DDD/1000 inhabitants/day in 2002). Glibenclamide was the most frequently used antidiabetic drug (12.63 DDD/1000 inhabitants/day in 2002).Conclusion: The insulin class had greater emphasis in therapy. Among OAD, the consumption rate of sulphonylureas decreased and the consumption rate of Biguanides and acarbose increased. By 2002 metformin replaced 90% of the buformin in use. The limited effect of therapeutic recommendations could explain these changes, although the out-of-date buformin and the non-micronized glibenclamide were still in use in 2002.     

Pharmacy and the health-care environment

The current revolution in the delivery of health care is examined, possibilities for the future are considered, and preparations for meeting the challenges of the future are discussed. The main elements in the revolution involve changes in the economic, business, and technological aspects of health-care delivery. The economic influences have included diagnosis-related groups (DRGs) and the Gramm-Rudman-Hollings legislation as it affects Medicare. Hospitals and hospital pharmacists have had to look closely at their own involvement and take measures to cut costs. The care of the elderly and the indigent and the issue of malpractice will require particular attention. Diversification and incorporation have brought many changes. Among them are the blurring of the traditional roles of pharmacy practice, as evidenced, for example, in the area of home health care. The changes made possible by technology are inseparable from the other current trends, and they add another dimension to health-care considerations--that of moral choices. Furthermore, pharmacy practitioner organizations will have to develop strategies for controlling the destiny of the profession in a corporate atmosphere. Pharmacists can achieve their full potential as society's drug therapy experts if they are flexible and creative enough to apply, in this new environment, the basic principles for which the profession has long stood.     

Recent developments in organizing and financing health-care services

Recent developments in the organization and financing of health-care services are described. All recent developments reflect an effort by both private and public payers to restrict use of health-care services, as well as to control price. Private use-review programs, such as second-surgical-opinion services and case-management services, are increasingly being used. The number of hospital admissions and length of patient stay continue to decline, but, because of increasing complexity of care, the cost of pharmaceutical services has not decreased proportionately. Points relating to health-care financing in the federal reconciliation budget effective May 1, 1986, are reviewed, as are other new federal regulations affecting the structure of services and terms of reimbursement under the Medicare and Medicaid programs. For Medicare, these include new scope objectives for professional review organizations, decreased return-on-equity payments to for-profit hospitals for outpatient services and to skilled nursing facilities, and elimination of waiver-of-liability presumptions for hospitals. Also, physicians must now identify specific services provided during each inpatient hospital visit. Most developments related to home health-care services pertain to limiting the cost of durable medical equipment. Alternative types of health care based on capitation funding, such as health maintenance organizations, competitive medical plans, and preferred provider organizations, will continue to grow in both the public and private sectors, and the use of private use-review programs for controlling costs is expected to accelerate in the next year.     

Practice of antidiabetic therapy in Hungary

Type 2 diabetes is one of the biggest public health problems of our age. In the present study the authors analyse the development of the therapy of type 2 diabetic patients. National antidiabetic consumption data and data of National Health Insurance Fund Administration (OEP) were used. From OEP database definite method were used to choose 1002 type 2 diabetic patients. The Hungarian therapeutic practice develops according to guidelines of multi centered studies, and the consumption of antidiabetics dynamically increases. Increasing the number of patients who get insulin therapy and among patients who get oral antidiabetics more of them get insulin resistance decreasing therapy. However the out-of-date drugs (non-micronized glibenclamide, buformin) are still in daily therapy. The authors revealed the ratio of diet and drug (monotherapy, combination therapy) therapy, the higher use of Sulfanylurea monotherapy than recommended and the use of unreasonable combinations.     

Pharmaceutical services in hospital-based home health-care agencies--1982

A survey of Medicare-certified hospital-based home health-care agencies was conducted in May 1982 to determine the type and extent of pharmaceutical services provided. A 12-page questionnaire was mailed to 243 directors of U.S. agencies that were identified from a 1976 directory. The questions elicited information about the characteristics of the director and agency, personnel, reimbursement, and scope of services. The overall response rate was 73.7%. Ninety-five percent of the agency directors were nurses. The median patient census of the agencies was 110. All agencies reported offering visiting-nurse services, 92% provided home health-aide services, and 46% offered home hospice services. Ninety-nine percent and 91% reported receiving reimbursement from Medicare and Medicaid, respectively. One fourth of the agencies provided home services that traditionally involve hospital pharmacists, including intravenous therapy (29%), home chemotherapy (18%), and total parenteral nutrition (18%). Although 85% of the agency directors reported using the services of a pharmacist, only 4% actually employed a pharmacist on their staff. The directors viewed educational programs, drug regimen review, and drug information services as the most important functions of pharmacists in home health-care agencies. Although these agencies provided an array of pharmaceutical services in 1982, very few pharmacists were actually employed. Additional studies are needed to re-evaluate the current status of pharmacy involvement in home health care.