The formulary decision-making process in a health maintenance organisation setting

The goal of a health maintenance organisation (HMO) is to provide high quality, cost-effective healthcare services and products which meet the needs of the membership. Providing and managing pharmaceutical products and services within the HMO is a major aspect of accomplishing this goal. Several decisions must be made in developing, implementing and maintaining a formulary system. The numbers of people seeking their healthcare from HMOs in the US has increased 4-fold in 10 years, and several model types of HMOs have developed, including network HMOs, group HMOs, independent practitioner associations and staff models. HMOs utilising formulary systems provided cover to 76% of enrollees in 1992. Formulary system management and decision making entails the use of open vs closed formularies and the role of the pharmacy and therapeutics (P & T) committee. Product selection takes into account efficacy, safety, costs, patient acceptance, ease of use, dosage forms, preparation requirements, stability and storage requirements and the reputation of the manufacturer and the service it provides. We list and describe various policy decisions which HMO pharmaceutical decision makers must address if the formulary system is to become an efficient tool for the HMO.     

Education and audit can improve the identification of excessive drinkers among medical inpatients

This study investigated the effect of education and audit on the identification and management of medical inpatients with excessive alcohol consumptions by use of a cross-sectional survey of medical and nursing notes, compared with historical controls. We report the proportion of medical and nursing notes containing qualitative and quantitative drinking histories, the use of the CAGE questionnaire, and notification of alcohol consumption in discharge summaries. A total of 1,979 out of 2,680 (74%) notes of eligible patients were examined. The number of medical notes containing quantitative alcohol histories rose from 175/792 (22%) among historical controls, to 242/690 (35%) after training of junior medical and nursing staff, and to 241/497 (48%) after feedback of results in a clinical audit meeting. The number of medical notes with no recorded alcohol history changed from 309/792 (39%) to 287/690 (42%) to 152/497 (31%), respectively (chi 2 for trend = 97.2, p < 0.0001). The number of nursing notes containing quantified alcohol histories rose from 31/792 (4%) among historical controls, to 123/690 (18%) after training, and to 237/497 (48%) after feedback of results in a clinical audit meeting. The number of nursing notes with no recorded alcohol history fell from 309/792 (90%), to 512/690 (74%), to 205/497 (41%) respectively (chi 2 for trend = 353.7, p < 0.0001). The proportion of patients found to be drinking excessively rose from 40/792 (5.1%) to 57/690 (8.3%) to 45/497 (9.1%) (chi 2 for trend = 8.25, p = 0.004). There was little worthwhile improvement in use of the CAGE questionnaire and in discharge summaries. Education and audit are effective ways of improving the identification of excessive drinkers by both junior doctors and nurses alike. Other aspects of management are less responsive.     

Multiple frequency bioelectrical impedance for the prediction of total body potassium in cystic fibrosis

The use of multiple frequency bioelectrical impedance analysis (MFBIA) was compared with single frequency bioelectrical impedance analysis (SFBIA) and anthropometry to estimate the size of the body cell mass (BCM) in a paediatric cystic fibrosis population. BCM was independently determined from the accepted gold standard reference of total body potassium (TBK). MFBIA was used to measure the impedance of the body at 248 frequencies from 4 kHz to 1 MHz. Data were analysed using Cole-Cole plots of reactance versus resistance. The limits of agreement procedure was used to determine the reliability and precision of the different techniques to predict values for TBK, in an individual subject. The results indicate that MFBIA with a precision of 12% offers little improvement over single frequency BIA but is better and more accurate than anthropometry for the prediction of TBK in an individual patient.     

The circumstances and scope for prevention of maxillofacial injuries in cyclists

A prospective study of cyclists with maxillofacial injuries attending Accident and Emergency departments in South Wales was carried out over a 12 month period. 65% of the 104 accident victims were aged under 14 years, and 81% were male. Only 14% were wearing helmets. Injuries were mapped to 9 facial zones. Nearly half the victims sustained injury to the central facial zone. There was an association between head injury (HI) and the location of impact on the face (p < 0.0001 Chi-square = 41 df = 8), the nature of the accident (p < 0.012 Chi-square = 10.9 df = 3), and type of injury in the impact zone (p < 0.007 Chi-square = 13.4 df = 4). More patients with facial injuries but without facial bone fractures sustained HIs than those with fractures. The facial skeleton may protect the brain by absorbing impact. The high incidence of midface injuries could be reduced by incorporating a facebar in helmet design.     

Enhancing the identification of excessive drinkers on medical wards: a 1-year follow-up study

This paper describes a 1-year follow-up study examining whether hospital ward doctors and nurses continue to take quantitative alcohol histories and provide brief intervention to problem drinkers on general medical wards after the introduction of a simple protocol. Regular training in the use of this protocol was stipulated in the annual service contract between the Health Authority and the Hospital Trusts. Improvements in staff practice persisted at 1-year follow-up, although it fell from a peak at an earlier phase of the study. The positive role of state purchasers of health services in sustaining improvements in clinical practice is discussed.     

Flow cytometric measurement of cell components other than DNA: virtues, limitations, and applications in gynecologic oncology.

Flow cytometry is a high-precision technique for rapid analysis and sorting of cells and particles. In theory, it can be used to measure any cell constituent, provided that a fluorescent tracer is available that reacts specifically and stoichiometrically with that constituent. The technique provides statistical accuracy, reproducibility, and sensitivity and allows simultaneous measurement of several constituents on a cell-to-cell basis. The main drawback of flow cytometry is the lack of visual control and structural information in solid tissues. Careful sample preparation, quality control of all staining and instrumentation procedures, and the use of immunohistologic or cytologic controls are essential for high-quality flow cytometric analysis. The technique has been used successfully for simultaneous measurement of DNA and tumor-associated antigens, oncogene products, proliferation markers, and markers for multidrug resistance in cultured cell lines and in cell suspensions prepared from solid tumors and cervical smears. Flow cytometry has the potential to play an important role in the study of carcinogenesis. With an appropriate panel of monoclonal antibodies, the technique can be used for screening, "biochemical" diagnosis of neoplasia, and rapid drug, hormone, and radiotherapy sensitivity tests.     

Laboratory facilities for investigating lipid disorders in the United Kingdom: results of the British Hyperlipidaemia Association survey.

AIMS: To determine the availability of facilities for the investigation of hyperlipidaemia in the United Kingdom. METHODS: A questionnaire was sent to all health districts in the United Kingdom. RESULTS: The response rate was 81%. All laboratories used enzymatic techniques to measure serum triglyceride and cholesterol concentrations, although there were differences in standardisation procedures. Reference ranges for serum lipids were quoted by 58% of laboratories while 50% quoted "desirable limits". Almost half specified that fasting blood samples were required. High density lipoprotein cholesterol concentrations were estimated by 75% and apolipoproteins AI and B by 14% of laboratories; there were differences in specimen type and considerable diversity in procedures used for measurement. CONCLUSIONS: Many laboratories were unaware of current recommendations for screening for hypercholesterolaemia in the community. The present survey indicated an urgent need for the introduction of better reference methods, standardisation, and quality assurance procedures before apolipoproteins become a routine part of coronary heart disease risk assessment.     

Cortical inflammation in Alzheimer disease but not dementia with Lewy bodies

BACKGROUND: There have been no previous studies on the role of inflammation in the brain for the second most common dementing disorder, dementia with Lewy bodies. OBJECTIVE: To investigate the degree of cortical inflammation in dementia with Lewy bodies (DLB) compared with Alzheimer disease (AD) and control brains. DESIGN AND MAIN OUTCOME MEASURES: Post-mortem tissue collection from a brain donor program using standardized diagnostic criteria. Brains collected from January 1, 1993, through December 31, 1996, were screened and selected only for the presence or absence of tau neuritic plaques. Results of immunohistochemistry for HLA-DR were quantified using area fraction counts. Counts were performed by investigators who were unaware of the diagnosis. Results were compared across groups using analysis of variance and posthoc testing. SETTING: A medical research institute in Sydney, Australia. PATIENTS: Eight brains with DLB and without the tau neuritic plaques typical of AD, 10 brains with AD and no Lewy bodies, and 11 nondemented controls without significant neuropathological features were selected from a consecutive sample. RESULTS: Compared with AD, DLB demonstrated significantly less inflammation in the form of HLA-DR-reactive microglia in all cortical regions (P<.001, posthoc). The level of inflammation in DLB was comparable to that seen in controls (P=.54, post hoc). CONCLUSIONS: Inflammation appears related to the tau neuritic plaques of AD. Despite similar clinical presentations, therapeutic anti-inflammatory strategies are not likely to be effective for pure DLB. Arch Neurol. 2000.