Effectiveness of medicines review with web-based pharmaceutical treatment algorithms in reducing potentially inappropriate prescribing in older people in primary care: a cluster randomized trial (OPTI-SCRIPT study protocol) Implementing Antibiotic Practice Guidelines through Computer-Assisted Decision Support: Clinical and Financial Outcomes Influence of Simple Computerized Feedback on Prescription Charges in an Ambulatory Clinic: A Randomized Clinical Trial The effects of expanded mental health benefits on treatment costs. Pharmacist-led medication review in patients over 65: a randomized, controlled trial in primary care. Tapering off benzodiazepines in long-term users: an economic evaluation. The value of inpatient pharmaceutical counselling to elderly patients prior to discharge. The Influence of “Stock out” on Health-Seeking Behavior of Low Income Women in Uyo Urban, Akwa Ibom State, Nigeria Safer Prescribing--A Trial of Education, Informatics, and Financial Incentives. Evaluation of a hospital-based community liaison pharmacy service in Northern Ireland Effect of Educational Interventions and Medical School Policies on Medical Students' Attitudes Toward Pharmaceutical Marketing Practices: A Multi-Institutional Study Economic and Policy Analysis of University-based Drug “Detailing Economic Analysis of Health Care Technology: A Report on Principles Effect of value-added utilities on prescription refill compliance and health care expenditures for hypertension. Design, rationale, and baseline characteristics of a cluster randomized controlled trial of pay for performance for hypertension treatment: study protocol Effectiveness of shared pharmaceutical care for older patients: RESPECT trial findings. Clinical and economic consequences of a reimbursement restriction of nebulised respiratory therapy in adults: direct comparison of randomised and observational evaluations How to build and evaluate an integrated health care system for chronic patients: study design of a clustered randomised controlled trial in rural China Financial and quality-of-life burden of dysfunctional uterine bleeding among women agreeing to obtain surgical treatment. Payment to healthcare professionals for patient recruitment to trials: systematic review and qualitative study. Capitation combined with pay-for-performance improves antibiotic prescribing practices in rural China. Prioritizing health problems in women in developing countries: comparing the financial burden of reproductive tract infections, anaemia and depressive disorders in a community survey in India. Effectiveness of a Multifaceted Intervention for Potentially Inappropriate Prescribing in Older Patients in Primary Care: A Cluster-Randomized Controlled Trial (OPTI-SCRIPT Study)
Background Potentially inappropriate prescribing in older people is common in primary care and can result in increased morbidity , adverse drug events , hospitalizations and mortality . In Irel and , 36 % of those aged 70 years or over received at least one potentially inappropriate medication , with an associated expenditure of over € 45 million . The main objective of this study is to determine the effectiveness and acceptability of a complex , multifaceted intervention in reducing the level of potentially inappropriate prescribing in primary care . Methods / design This study is a pragmatic cluster r and omized controlled trial , conducted in primary care ( OPTI-SCRIPT trial ) , involving 22 practice s ( clusters ) and 220 patients . Practice s will be allocated to intervention or control arms using minimization , with intervention participants receiving a complex multifaceted intervention incorporating academic detailing , medicines review with web-based pharmaceutical treatment algorithms that provide recommended alternative treatment options , and tailored patient information leaflets . Control practice s will deliver usual care and receive simple patient-level feedback on potentially inappropriate prescribing . Routinely collected national prescribing data will also be analyzed for nonparticipating practice s , acting as a contemporary national control . The primary outcomes are the proportion of participant patients with potentially inappropriate prescribing and the mean number of potentially inappropriate prescriptions per patient . In addition , economic and qualitative evaluations will be conducted . Discussion This study will establish the effectiveness of a multifaceted intervention in reducing potentially inappropriate prescribing in older people in Irish primary care that is generalizable to countries with similar prescribing challenges . Trial registration Current controlled trials IS RCT Physicians ' decisions control between 70 % and 80 % of all health care dollars spent [ 1 - 3 ] , and many strategies to influence or control physician decision making have been advocated . These strategies include education , peer review with feedback , administrative interventions , financial incentives and penalties , critical pathways , and , most recently , nationally derived guidelines [ 2 , 4 ] . To date , none of these strategies has been clearly effective [ 4 ] . Berwick [ 5 ] has outlined the inherent flaws in many of these strategies . He concedes that these methods may lead to predictable care but notes that they can not lead to continual improvement of care . Nowhere in health care are these strategies to control or influence physicians more prevalent than in the area of drug use , particularly use of antimicrobial agents [ 6 ] . The hospital-wide use of drugs and the involvement of various health care providers create a system of diffuse responsibility , enormous variation , and escalating costs [ 6 - 9 ] . The United States currently spends $ 40 billion annually on pharmaceuticals ; this is 8 % of the total cost of health care [ 3 , 7 - 9 ] . Prescription drugs now constitute between 5 % and 20 % of an individual hospital 's total budget [ 7 ] . Antimicrobial agents are one of the costliest categories of drug expenditures in hospitals , accounting for approximately 20 % to 50 % of total spending on drugs [ 9 - 14 ] . Investigations in various clinical practice setting s have indicated that as much as 50 % of antibiotic use is inappropriate [ 14 - 17 ] . The consequences of this have been addressed in terms of antimicrobial resistance [ 18 , 19 ] , adverse drug reactions [ 15 , 17 ] , and cost [ 11 - 14 ] . In response to these pressures , professional societies and individual investigators have outlined methods with which to improve antibiotic use [ 20 - 29 ] . Most of these methods ( for example , drug formularies ) use some form of a control mechanism , and , to date , experience with them has been mixed [ 11 , 16 , 25 , 27 , 28 ] . Kassirer [ 30 ] has challenged the health care system to develop strategies that inform rather than enforce or control medical decisions . For more than a decade , we have been developing and investigating clinical management programs that augment and inform clinical decision making , in addition to focusing on continual quality improvement [ 31 , 32 ] , in antibiotic therapy , infection control surveillance , and the safety of drug use . These programs were design ed to provide continuous surveillance and computer-assisted decision support [ 33 , 34 ] to all clinicians responsible for inpatient care in a general hospital . The hallmark of these computer-assisted decision support programs was local clinician-derived consensus practice guidelines [ 5 , 31 , 34 , 35 ] that were programmed into a hospital information system as rules , algorithms , and predictive models . These programs managed antibiotic use at three basic levels : prophylactic use , empiric use , and therapeutic use . We review the clinical and process outcomes and the financial effects of these hospital-wide decision support programs during a 7-year period . Methods LDS Hospital , located in Salt Lake City , Utah , is a 520-bed private , community , acute-care referral hospital that serves as a teaching facility for the University of Utah Schools of Medicine , Nursing , and Pharmacy . The hospital provides most clinical services but not general pediatric care . An integrated , clinical ly oriented hospital information system has been under development at the institution for more than 20 years [ 36 ] . This system routinely collects and stores all patient data from multiple sources throughout the hospital . The system currently serves as the hospital 's clinical computing system , providing clinical information management and establishing computer-based patient records . The computer-based patient record contains both clinical and financial data . The financial data are derived from a st and ard cost-manager microcomputer software system that is linked to the clinical information system [ 37 , 38 ] . The information system also provides online clinical decision support through its expert system capabilities . Infectious diseases surveillance and therapeutics was the first medical domain to use the expert system features of the hospital information system on a widespread clinical basis [ 39 ] . The clinical decision support systems and the implementation methods for this domain were developed , tested , and implemented by clinical investigators in the Division of Infectious Diseases at LDS Hospital [ 37 - 52 ] . The process used to develop the local consensus guidelines for antimicrobial use was similar to the approach described by East and colleagues [ 34 ] . Our approach also included thorough evaluations of published reports , use of national guidelines and local expert opinion , and exhaustive analyses of the LDS Hospital patient data base ; we subsequently developed step-wise logistic regression models [ 48 , 49 ] . Through various committee representations , we also frequently consulted the medical staff of LDS Hospital ; in these consultations , we presented data and interim results . Using the aforementioned formal techniques [ 34 , 35 ] , the staff also helped develop , test , and implement the clinical practice guidelines that were embedded in the decision support programs . The practice guidelines were encoded into the knowledge base of the hospital information system as rules , algorithms , and predictive models . This allowed for decision support at the point of care , with feedback to physicians in real time . Thus , guideline application was patient specific , and recommendations corresponded to actual clinical conditions at a particular point in time . Feedback to physicians was open looped [ 53 ] , and the physicians ultimately decided whether or not to follow the recommendations . Since 1985 , many of these clinical decision support programs and guidelines have been prospect ively developed and tested in the patient population s of LDS Hospital , often in r and omized studies . Decision support programs have been systematic ally exp and ed to include comprehensive , institution-wide antibiotic management programs . These decision support programs were design ed to comprehensively manage all antibiotic agents used in the institution throughout the continuum of hospital care : 1 ) prophylactic [ surgical ] antibiotic use ; 2 ) empiric antibiotic use [ for suspected infection without microbiological data ] ; and 3 ) therapeutic antibiotic use ( for established infection with microbiological data ) . These programs continually track and assist physicians in managing each patient treated with an antibiotic at LDS Hospital and in all aspects of antibiotic use ; no antibiotic can be prescribed at LDS Hospital without being affected by these decision support programs . The methods used in these programs have been described elsewhere [ 37 - 52 ] . These programs are continually up date d as medical knowledge and the health care delivery system change , both locally and nationally . The surgical prophylactic decision support programs were developed with our surgical colleagues and result ed in strategies that ensured appropriate case selection , delivery time , intra-operative dosing , and duration of antibiotic use rather than solely concentrating on the specific antibiotic agent or class of agents for each surgical procedure [ 41 , 42 , 45 ] . The empiric and therapeutic antibiotic decision support programs provide information to the clinician in the form of computer-generated alerts or suggestions on the following : the presence of resistant pathogens ; untreated infections ; an incorrect dose , route , or interval of an antibiotic ; the absence of current renal function data ; the need for serum drug levels ; population -based probabilities of infections in relation to specific patient variables ; and cost-effective alternatives ( for example , oral therapy or narrower-spectrum agents ) [ 43 , 48 , 49 ] . Furthermore , these management programs monitor patients for excessive or suboptimal antibiotic doses , depending on the patients ' current renal function status [ 46 , 47 ] , and they address the prevention , early detection , and archiving of adverse drug events associated with these agents [ 44 , 46 , 50 ] . All but one of the computer-assisted antibiotic decision support programs described were in clinical use throughout the study period ; the exception was the adverse drug event program , which has been used since 1989 . Beginning in 1985 , investigators in the infectious disease division developed data base analysis programs that quantify antibiotic use and expenditures , identify prescriber and diagnosis-related groups for patients receiving antibiotics , track antibiotic resistance patterns , and distinguish therapeutic from prophylactic use of antibiotics . The reports generated by these data base analysis programs summarize antibiotic use by specific agent and place them in the following categories : numbers of patients treated , total milligrams administered , total doses administered , defined daily doses per 100 occupied bed-days [ 12 , 13 , 54 ] , and total amount spent . We used the number of defined daily doses per 100 occupied bed-days because it is a st and ardized technical unit of measurement that estimates drug use . A defined daily dose is based on the average adult maintenance dose ( usually in grams ) for the primary indication of the drug and is adjusted per 100 occupied bed-days . The concept of the defined daily dose per 100 occupied bed-days was established by a joint project of the Nordic Council on Medicines and the World Health Organization Center for Drug Collaboration Statistics [ 12 , 13 , 54 ] . Because the defined daily dose per 100 occupied bed-days is independent of cost ( which eliminates confounding introduced by the buying practice s of group purchasing organizations ) and differences in dose forms , it establishes a st and ardized basis for comparing drug use . The World Health Organization has agreed that the defined daily dose method of analysis can be Pharmaceuticals account for a significant portion of health care costs and are an important target for attempts at cost reductions . While many techniques have been shown effective , most are re source -intensive , have demonstrated fatigue after the intervention is ceased , and have been directed at specific items rather than total charges . The authors design ed a computerized program to feed back prescription charges . The intervention is easy to execute , inexpensive , and can be maintained indefinitely . The intervention was performed in a r and omized , prospect i ve , controlled trial with the medical residents of a large county hospital . The goal was to reduce total prescribing charges and produce a meaningful financial result . The intervention reduced the mean charge for a prescription by 6.7 % ( P < 0.025 ) , but with a long latent period and minimal impact on resident knowledge of drug charges . Significant differences were seen only at the end of the study . The program was viewed positively by the residents . The low cost of the intervention yielded a benefit-to-cost ratio in excess of 50:1 . Because of computerization and ongoing patient and resident r and omization at the study hospital , added costs of this r and omized trial in terms of computer time and research assistance were less than $ 1,000 BACKGROUND Mental health disorders represent one of the most common problems facing adults in the labor force . It is estimated that within a 12-month period nearly 30 % of the US population experiences some diagnosable mental health or addictive disorder . This study examines the impact that corporate benefit policies can have on mental health treatment costs . AIMS To measure the effects of a change in mental health benefit design on treatment expenditures for employees of a large US-based company . METHODS Data came from mental health treatment administrative cl aims and eligibility information provided by the company and a comparable set of cl aims for a r and omly selected control group for the years 1995 - 1998 . We measure the effect of a change in mental health benefits consisting of three major elements : a company-wide effort to destigmatize mental illness ; reduced cost-sharing for mental health treatment ; and the implementation of a provider network that emphasized access to non-physician mental health specialists . We use a two-part regression model within a difference in differences framework to examine outpatient , pharmaceutical , and combined outpatient and pharmaceutical expenditures between the treatment company and the control group . RESULTS We find that the program led to a statistically significant dollar 17 increase in outpatient costs ( excluding pharmaceutical costs ) per employee . Similar to outpatient care we find that the benefit change was associated with a statistically significant increase in pharmaceutical costs of about dollar 15 . DISCUSSION The results reveal that the mental health benefit expansion at the company led to a significant increase in aggregate mental health expenditures among employees . However , the aggregate increase in cost masks a number of interesting underlying trends in mental health utilization . First , conditional upon any mental health treatment , mental health costs were virtually unchanged before and after the benefit change . Conditional on any use , outpatient and pharmaceutical expenditures went in opposite directions , with outpatient expenditures falling and pharmaceutical expenditures increasing . IMPLICATION S FOR HEALTH CARE PROVISION AND USE Private sector initiatives can increase use of mental health care treatment through decreased cost-sharing , improved access to specialty providers , and destigmatization of mental disorders . IMPLICATION S FOR HEALTH CARE POLICY FORMULATION : Given that the vast majority of people in the US get their health insurance through employer-sponsored health insurance , efforts on the part of the private sector to recognize and treat serious chronic illnesses such as mental disorder in a proactive manner should be encouraged . IMPLICATION S FOR FUTURE RESEARCH While the aggregate cost of corporate initiatives to improve access to quality mental health care is frequently examined , it is also important to decompose the aggregate cost changes into effects from a change in the rate of initiation and changes in utilization conditional upon initiation BACKGROUND regular medication review has been recommended for those over 75 and those on multiple drug therapy . Pharmacists are a potential source of assistance in review ing medication . Evidence of the benefits of this process is needed . OBJECTIVE to study the effect of medication review led by a pharmacist on resolution of pharmaceutical care issues , medicine costs , use of health and social services and health-related quality of life . DESIGN r and omized , controlled trial . SETTING general medical practice s in the Grampian region of Scotl and . SUBJECTS patients aged at least 65 years , with at least two chronic disease states who were taking at least four prescribed medicines regularly . METHODS pharmacists review ed the drug therapy of 332 patients , using information obtained from the practice computer , medical records and patient interviews . In 168 patients , a pharmaceutical care plan was then drawn up and implemented . The 164 control patients continued to receive normal care . All outcome measures were assessed at baseline and after 3 months . RESULTS all patients had at least two pharmaceutical care issues at baseline . Half of these were identified from the prescription record , the rest from notes and patient interview . Of all the issues , 21 % were resolved by information found in notes and 8.5 % by patient interview . General practitioners agreed with 96 % of all care issues documented on the care plans in the intervention group . At the time of follow-up , 70 % of the remaining care issues had been resolved in the intervention group , while only 14 % had been resolved in the control group . There were no changes in medicine costs or health-related quality of life in either group . There were small increases in contacts with health-care professionals and slightly fewer hospital admissions among the intervention group than the control group . CONCLUSIONS pharmacist-led medication review has the capacity to identify and resolve pharmaceutical care issues and may have some impact on the use of other health services BACKGROUND Discontinuation of benzodiazepine usage has never been evaluated in economic terms . This study aim ed to compare the relative costs and outcomes of tapering off long-term benzodiazepine use combined with group cognitive behavioural therapy ( TO+CBT ) , tapering off alone ( TOA ) and usual care . METHOD A r and omised controlled trial was conducted , incorporating a cost-effectiveness analysis from a societal as well as a pharmaceutical perspective . The cost of intervention treatment , prescribed drugs , healthcare services , productivity loss , and patients ' costs were measured using drug prescription data and cost diaries . Costs were indexed at 2001 prices . The principal outcome was the proportion of patients able to discontinue benzodiazepine use during the 18-month follow-up . A secondary outcome measure was quality of life ( Health Utility Index Mark III [ HUI-3 ] and the Medical Outcomes Study 36-item Short-Form Health Survey [ SF-36 ] ) . RESULTS A total of 180 patients were r and omised to one of TO+CBT  ( n = 73 ) , TOA ( n = 73 ) or usual care ( n = 34 ) . Intervention treatment costs were an average of 172.99Euro per patient for TO+CBT and 69.50Euro per patient for TOA . Both treatment conditions significantly reduced benzodiazepine costs during follow-up compared with usual care . The incremental cost-effectiveness ratios ( ICERs ) showed that , for each incremental 1 % successful benzodiazepine discontinuation , TO+CBT cost 10.30 - 62.53Euro versus usual care , depending on the study perspective . However , TO+CBT was extendedly dominated or was dominated by TOA . This result ed in ICERs of 0.57Euro , 10.21Euro and 48.92Euro for TOA versus usual care from the limited pharmaceutical , comprehensive pharmaceutical and societal perspective , respectively . CONCLUSIONS TO+CBT and TOA both led to a reduction in benzodiazepine costs . However , it remains uncertain which healthcare utilisation has a causal relationship with long-term benzodiazepine consumption or its treatment . Although the ICERs indicated better cost effectiveness for TOA than for TO+CBT , the differences were relatively small . The addition of group CBT to tapering off had no clinical or economic advantages . Extrapolation of our data showed that the investment in TOA was paid back after 19 months when corrected for treatment gain with usual care AIMS The use of medication and information discharge summaries ( MIDS ) has become a st and ard procedure in many hospitals . We have evaluated if these summaries , together with in-patient pharmaceutical counselling backed up with a simple medicine reminder card , may help with the delivery of seamless pharmaceutical care . METHODS Elderly patients prescribed more than four items discharged to their own home received the st and ard discharge policy including a recently introduced MIDS and medicine reminder card . Each patient 's GP was sent a copy on discharge . Pre-discharge a pharmacist counselled study patients about their medicines and compliance . A research pharmacist visited patients in their home approximately 2 - 3 weeks and at 3 months post-discharge to determine their drug knowledge , compliance , home medicine stocks and any healthcare related events . RESULTS Forty-three study and 40 control patients completed both visits . Their mean ( s.d . ) ages were 80.2 ( 5,7 ) and 81.1 ( 5,8 ) years and they were prescribed 7.1 ( 1.8 ) and 7.1 ( 2.3 ) items , respectively . At visit 1 knowledge ( P < 0.01 ) and compliance ( P < 0.001 ) was better in the study group . At visit 2 compliance had improved in the study group ( P < 0.001 ) . Unplanned visits to the GP and readmission to hospital amongst the study group were 19 and 5 , respectively , which were both significantly less ( P < 0.05 ) than 27 and 13 in the control group . At visit 2 for the study group the 24 unplanned GP visits and three re-admissions were significantly ( P < 0.05 ) less than the respective 32 and 15 in the control group . At visit 1 , two study group patients had altered their own medication compared with 10 control patients . At visit 2 these reduced to 0 and 4 , respectively . CONCLUSIONS In-patient pharmaceutical counselling , linked to a medication and information discharge summary and a medicine reminder card , contributed to better drug knowledge and compliance together with reduced unplanned visits to the doctor and re-admissions . A pharmaceutical domiciliary visit consoli date d the improved healthcare outcomes The “ Health for All Project ” ( HFAP ) policy in Nigeria was complemented by the National Drug Policy to ensure constant availability of high quality drugs and medical consumables at affordable prices to citizens in public hospitals . Apart from strengthening the utilization of health services , the project also sought to improve health care delivery for the poor who could not afford the high cost of drugs in private clinics and pharmaceutical stores . Employing a survey method with stratified and systematic r and om techniques , the study found failed expectations in the promises of HFAP policy among the 1250 low-income women in Uyo urban . In the face of “ stock out ” where most drugs , pharmaceuticals , and medical supplies are consistently not available for dispensing in public hospitals and health centers poor urban women resorted to alternative health care in prayer houses , herbal homes , patent medicine vendors , health workers homes , and traditional birth attendants . The study reported that stock out in government health facilities result ed in health hazards and the relapse of illnesses as a result of non-adherence to treatment regime and exposure to fake , expired , and adulterated drugs . A renewed commitment in health care delivery in Nigeria is called for if poor women are to be really empowered BACKGROUND High-risk prescribing and preventable drug-related complications are common in primary care . We evaluated whether the rates of high-risk prescribing by primary care clinicians and the related clinical outcomes would be reduced by a complex intervention . METHODS In this cluster-r and omized , stepped-wedge trial conducted in Tayside , Scotl and , we r and omly assigned participating primary care practice s to various start date s for a 48-week intervention comprising professional education , informatics to facilitate review , and financial incentives for practice  s to review patients ' charts to assess appropriateness . The primary outcome was patient-level exposure to any of nine measures of high-risk prescribing of nonsteroidal antiinflammatory drugs ( NSAIDs ) or selected antiplatelet agents ( e.g. , NSAID prescription in a patient with chronic kidney disease or coprescription of an NSAID and an oral anticoagulant without gastroprotection ) . Prespecified secondary outcomes included the incidence of related hospital admissions . Analyses were performed according to the intention-to-treat principle , with the use of mixed-effect models to account for clustering in the data . RESULTS A total of 34 practice s underwent r and omization , 33 of which completed the study . Data were analyzed for 33,334 patients at risk at one or more points in the preintervention period and for 33,060 at risk at one or more points in the intervention period .  Targeted high-risk prescribing was significantly reduced , from a rate of 3.7 % ( 1102 of 29,537 patients at risk ) immediately before the intervention to 2.2 % ( 674 of 30,187 ) at the end of the intervention ( adjusted odds ratio , 0.63 ; 95 % confidence interval [ CI ] , 0.57 to 0.68 ; P<0.001 ) . The rate of hospital admissions for gastrointestinal ulcer or bleeding was significantly reduced from the preintervention period to the intervention period ( from 55.7 to 37.0 admissions per 10,000 person-years ; rate ratio , 0.66 ; 95 % CI , 0.51 to 0.86 ; P=0.002 ) , as was the rate of admissions for heart failure ( from 707.7 to 513.5 admissions per 10,000 person-years ; rate ratio , 0.73 ; 95 % CI , 0.56 to 0.95 ; P=0.02 ) , but admissions for acute kidney injury were not ( 101.9 and 86.0 admissions per 10,000 person-years , respectively ; rate ratio , 0.84 ; 95 % CI , 0.68 to 1.09 ; P=0.19 ) . CONCLUSIONS A complex intervention combining professional education , informatics , and financial incentives reduced the rate of high-risk prescribing of antiplatelet medications and NSAIDs and may have improved clinical outcomes . ( Funded by the Scottish Government Chief Scientist Office ; Clinical Trials.gov number , NCT01425502 . ) Objective : To evaluate the impact of a hospital based community liaison pharmacy service on a range of outcomes in patients aged more than 55 years and taking more than 3 prescribed drugs , who had been admitted to the medical unit of a district general hospital in Northern Irel and . Methods : Having recruited 243 patients , a total of 162 patients completed the full protocol ( 81 r and omly assigned to intervention and 81 to control  ; mean age of control patients 75 years ; mean age of intervention patients 73 years ) . The interventions by the community liaison pharmacist included : preparation of an accurate medication record following a full review of current medication use ; medication counselling ; provision of a medicines record sheet informing the patient how to take their drugs ; provision of a pharmaceutical discharge letter detailing changes made to drug therapy ( this was faxed to the patient 's GP and community pharmacist on the day of discharge ) ; provision of a Medicines Helpline . Results : The key findings were as follows : problems were identified in 80 % of the intervention patients ' prescription charts , 49 % of which related to drug omissions from the patients ' domiciliary prescriptions . The GP practice record was the most accurate ( mean error rate 12.6 % ) while the GP referral letter was the least accurate ( mean error rate 47.3 % ) source of medication information . Drugs patients brought to hospital were also an inaccurate source ( mean error rate 44.0 % ) . The intervention group patients , when compared with control patients , had a significant reduction ( P=0.005 ) in drug mismatch between drugs prescribed at discharge and taken at home , and had a greater knowledge of their drug regimen 10–14 days after discharge ( P |Ld 0.001 ) . The vast majority of patients ( 96 % ) felt that the provision of a medicine helpline was a useful service . Conclusions : The study indicated clear benefits from the involvement of a hospital based community liaison pharmacist in achieving seamless pharmaceutical care between the primary and secondary healthcare setting Purpose To determine the effect of educational interventions on medical students ' attitudes toward pharmaceutical industry marketing practice s and whether restrictive medical school policies governing medicine – industry interactions are associated with student support for banning such interactions . Method Prospect i ve cohort study involving the graduating classes of 2009 ( intervention , n = 474 ) and 2010 ( control , n = 459 ) at four U.S. medical schools . Intervention students experienced a former pharmaceutical representative 's presentation , faculty debate , and a Web-based course . Both groups completed baseline and follow-up attitude surveys about pharmaceutical marketing . Results A total of 482 students ( 51.6 % ) completed both surveys . In regression analyses , intervention students were more likely than control students to think that physicians are strongly or moderately influenced by pharmaceutical marketing ( OR , 2.29 ; 95 % CI , 1.46–3.59 ) and believed they would be more likely to prescribe a company 's drug if they accepted that company 's gifts and food ( OR , 1.68 ; 95 % CI , 1.12–2.52 ) . Intervention students were more likely to support banning interactions between pharmaceutical representatives and students ( OR , 4.82 ; 95 % CI , 3.02–7.68 ) and with physicians ( OR , 6.88 ; 95 % CI , 4.04–11.70 ) . Students from schools with more restrictive policies were more likely to support banning interactions between pharmaceutical representatives and students ( OR , 1.99 ; 95 % CI , 1.26–3.16 ) and with physicians ( OR , 3.44 ; 95 % CI , 2.05–5.79 ) . Conclusions Education about pharmaceutical marketing practice s and more restrictive policies governing medicine – industry interactions seem to increase medical students ' skepticism about the appropriateness of such marketing practice s and disapproval of pharmaceutical representatives in the learning environment The cost-effectiveness of quality assurance programs is often poorly documented , especially for innovative approaches . The authors analyzed the economic effects of an experimental educational outreach program design ed to reduce inappropriate drug prescribing , based on a four-state r and omized controlled trial ( N = 435 physicians ) . Primary care physicians r and omized into the face-to-face group were offered two individualized educational sessions with clinical pharmacists , lasting an average of 18 minutes each , concerning optimal use of three drug groups that are often used inappropriately . After the program , expenditures for target drugs prescribed by these physicians to Medicaid patients decreased by 13 % , compared with controls ( P = 0.002 ) ; this effect was stable over three quarters . Implementation of this program for 10,000 physicians would lead to projected drug savings ( to Medicaid only ) of $ 2,050,000 , compared with re source costs of $ 940,000 . Net savings remain high , even after adjustment for use of substitution medications . Although there was a ninefold difference in average preintervention prescribing levels between the highest and lowest thirds of the sample , all groups reduced target drug expenditures at the same rate . Targeting of higher-volume prescribers would thus further raise the observed benefit-to-cost ratio from approximately 1.8 to at least 3.0 . Net benefits would also increase further if non-Medicaid savings were added , or if the analysis included quality -of-care considerations . Although print material s alone may be marginally cost-effective , print plus face-to-face approaches offer greater net benefits . The authors conclude that a program of brief , face-to-face “ detailing ” visits conducted by academic rather than commercial sources can be a highly cost-effective method for improving drug therapy decisions . Such an approach makes possible the enhancement of physicians ' clinical expertise without relying on restriction of drug choices Preamble Although economic outcomes research is an evolving field in health services research , there are correct and incorrect ways to conduct and report on economic outcomes studies . Research practice s that help to minimize real or perceived bias will increase the quality and usefulness of such studies for those who sponsor , publish , and use them . Because of public concerns about the potential for bias in the design , analysis , and reporting of economic analyses of health care technology , we formed a task force to develop principles to enhance the credibility of these studies . The Task Force on Principles for Economic Analysis of Health Care Technology included participants from academia , the pharmaceutical industry , the public sector , and private research organizations . As health care re sources become increasingly constrained , the information used to make re source allocation decisions must be as reliable , valid , and free of bias as possible . Getting it right at the level at which economic results are produced will help to protect consumers and will advance the health of the public . Bias stems from two broad categories : lack of appropriate independence for research ers and lack of consensus about methods . We focused heavily on the first of these categories for two major reasons . First , few have yet considered the unique issues of research er independence in economic outcomes research [ 1 , 2 ] . Second , other investigators have begun to consider and define proper methods for economic outcomes work ( an area of considerable controversy ) [ 3 - 5 ] . We also looked closely at the requirements for the reporting of economic analyses , which are intended to ensure method ologic transparency and accountability . The Need for Voluntary Guidelines Widespread use of economic analysis as part of the development of pharmaceutical , biotechnologic , and medical devices is relatively new . To date , many economic analyses of health care have focused on pharmaceutical agents , and many such studies have been funded by pharmaceutical companies . Results of these economic outcomes studies are used by medical technology firms to support the pricing and marketing of new interventions and to influence national health care systems and third-party payers in their development of coverage and payment decisions . Managed care organizations , hospitals , and government-subsidized health care programs rely on economic analysis of medical technology to help make formulary purchasing and utilization decisions . Physicians may use the results of these analyses to help guide treatment and prescription decisions . Health care economic outcomes projects are sponsored and conducted by pharmaceutical , biotechnologic , and medical device companies ; government agencies ; nonprofit foundations ; academic investigators ; and private research and consulting firms . The st and ards and methods used to evaluate the safety and efficacy of pharmaceutical products in r and omized , controlled trials have evolved over 50 years of collaboration among research ers in private , public , and academic setting s. Compared with those established to ensure the safety and efficacy of clinical trials , the principles and methods for the conduct of economic studies of health care technology are far less developed . Problems of conduct , reporting , and bias exist in all types of research [ 6 - 14 ] . In response , codes of conduct , such as those developed by the American Federation for Clinical Research and the Institute of Medicine , have been developed for many scientific disciplines [ 15 - 24 ] . These are good models on which to base principles of conduct for economic outcomes analysis . Although many published principles apply to economic studies , others should be modified and new ones should be developed to guide the conduct and reporting of economic outcomes analyses . Economic outcomes research requires unique guidelines for the following reasons : 1 ) As a field , it continues to evolve and is often misunderstood by end users ; 2 ) peer review of it requires special expertise that often exceeds the capabilities of review ers and scientific journals ; 3 ) it often uses secondary data and requires that many assumptions be made [ for example , attribution of a dollar cost to a unit of re source use ] ; 4 ) it offers unique method ologic choices , such as which types of costs to include ( direct , indirect , intangible , induced ) , which perspective to apply ( that of society , payer , provider , patient ) , which design to adopt ( cost- identification , costbenefit , cost-effectiveness , costutility ) , from where to obtain costs [ indemnity data base , managed care or capitated data base , hospital cost systems , Medicare , Medicaid ] , and whether to collect re source consumption data prospect ively or retrospectively through various modeling techniques ; and 5 ) economic studies play an increasingly important role in health care decision making because of increasing financial constraints throughout the health care industry . The financial and medical implication s of decision making done on the basis of these studies , coupled with the lack of widely accepted guidelines about the conduct and reporting of economic analyses , undermine the credibility of this research . A major issue is that the primary source of funding for this research is often the primary financial beneficiary of positive study results . Unfortunately , even valid studies done under the best of circumstances may be suspect [ 25 - 29 ] . This has led at least one major journal to conclude that these analyses should be viewed much like editorials or review articles are viewed in terms of potential for conflicts of interest [ 30 ] . We developed the guidelines reported here after extensive consultation with experts from the public , private , and academic sectors . We recommend that research ers and sponsors adhere to these guidelines , and we suggest they state publicly within their manuscripts that they have done so . End users , including journal editors and readers , consumers , and social decision makers , may then feel more secure in accepting the results of the research , while recognizing that intensive critique of the research will always be necessary . Operations of the Task Force The Task Force on Principles for Economic Analysis of Health Care Technology was initiated and organized by faculty from the Leonard Davis Institute ( LDI ) Center for Health Policy of the University of Pennsylvania . However , because not all LDI faculty were involved , this paper does not represent an official LDI position statement . The Task Force was funded by a coalition of pharmaceutical companies ( Appendix A ) . Funding was also requested ( but not obtained ) from various government and private foundations . All funding was provided in the form of unrestricted research grants or gifts to the University of Pennsylvania . Guidelines derive their credibility in part from the composition of the panel that creates them and the process by which they are developed . C and i date s for participation in the Task Force from the private sector and the academic research community were identified by the frequency with which they were cited in the health economics literature , which was obtained using a MEDLINE search of literature related to economic analyses of medical technology published between 1983 and 1992 . Approximately 15 members attended each meeting . Minutes were distributed after each meeting and approved by all members present . Members from the sponsoring pharmaceutical companies and the academic organizers rotated so that they numbered three and one , respectively , at the table for each formal Task Force meeting . Several professional and governmental organizations , including the Institute of Medicine , the Agency for Health Care Policy and Research , the Food and Drug Administration ( FDA ) , the Health Care Financing Administration , the Centers for Disease Control and Prevention , and a managed care organization , were asked to suggest persons who might participate . In addition , other organizations with a stake in economic analyses were each asked to suggest a person who , because of his or her professional background , had extensive knowledge of or experience with economic analyses . An academic pharmacist , an academic research er , a private research er , an ethicist and patient advocate , and an attorney specializing in medical ethics rounded out the Task Force ( Appendix B ) . Two members withdrew from participation . A small audience consisting of industry sponsors , academic organizers , staff , and a few other interested parties were invited to each meeting and allowed to comment . Four formal meetings of the Task Force were held in Philadelphia during 1993 and 1994 , and the most substantial work was done by various subcommittees between these meetings . The three main subcommittees were titled Ethical Conduct , Responsibility and Control ( the findings of these two subcommittees were later merged into one report ) , and Reporting Requirements for Economic Evaluations ( Appendix C ) . The Task Force was assisted by a professional facilitator . Although Task Force members sought consensus wherever possible on the key issues , consensus was not forced and recommendations were issued only when substantial agreement existed among the members . Task Force members were not asked to formally represent any organization . Formal endorsement of the final document was not sought . Copies of this report will be distributed to all organizations that were asked to suggest a participant and to other parties who responded to announcements placed in The New Engl and Journal of Medicine , Scrip , and the Pink Sheet . The Task Force findings will also be reported at academic conferences , medical profession meetings , and appropriate trade conventions . Findings and Recommendations Valid approaches to economic analyses can be defined ; acceptable methods can be differentiated from unacceptable ones . Bias in economic research stems from two major sources : lack of appropriate independence for A r and omised trial was undertaken to discern the effect of pharmacy-based value-added utilities on prescription refill compliance with antihypertensive therapy and subsequent health care expenditures . The subjects were 304 Medicaid beneficiaries from the state of Florida , previously untreated for mild to moderate hypertension , prescribed 240 mg of calcium channel antagonist verapamil once daily and monitored regarding prescription refill compliance and health service utilisation for one year . Subjects provided informed consent and were r and omly assigned to one of four experimental groups : ( 1 ) the control cohort received st and ard pharmaceutical care with each dispensing of antihypertensive therapy , ( 2 ) the second cohort received st and ard pharmaceutical care and was mailed a medication-refill reminder ten days prior to each sequential refill date , ( 3 ) the third cohort received st and ard pharmaceutical care and was provided unit-of-use packaging with each prescription-refill request and ( 4 ) the fourth cohort received st and ard pharmaceutical care , mailed medication-refill reminders and unit-of-use packaging . Analysis of variance ( ANOVA ) procedures revealed that patients receiving mailed prescription-refill reminders , unit-of-use packaging or a combination of both interventions achieved a significant ( P < or = 0.05 ) increase in the Medication Possession Ratio ( MPR ) for antihypertensive therapy relative to controls . Receipt of both interventions result ed in a significant ( P < or = 0.05 ) improvement in the MPR for antihypertensive therapy relative to all other groups no significant difference was discerned between groups receiving either mailed prescription-refill reminders or unit-of-use packaging . ( ABSTRACT TRUNCATED AT 250 WORDS Background Despite compelling evidence of the benefits of treatment and well-accepted guidelines for treatment , hypertension is controlled in less than one-half of United States citizens . Methods / design This r and omized controlled trial tests whether explicit financial incentives promote the translation of guideline -recommended care for hypertension into clinical practice and improve blood pressure ( BP ) control in the primary care setting . Using constrained r and omization , we assigned 12 Veterans Affairs hospital outpatient clinics to four study arms : physician-level incentive ; group-level incentive ; combination of physician and group incentives ; and no incentives ( control ) . All participants at the hospital ( cluster ) were assigned to the same study arm . We enrolled 83 full-time primary care physicians and 42 non-physician personnel . The intervention consisted of an educational session about guideline -recommended care for hypertension , five audit and feedback reports , and five disbursements of incentive payments . Incentive payments rewarded participants for chart-documented use of guideline -recommended antihypertensive medications , BP control , and appropriate responses to uncontrolled BP during a prior four-month performance period over the 20-month intervention . To identify potential unintended consequences of the incentives , the study team interviewed study participants , as well as non-participant primary care personnel and leadership at study sites . Chart review s included data collection on quality measures not related to hypertension . To evaluate the persistence of the effect of the incentives , the study design includes a washout period . Discussion We briefly describe the rationale for the interventions being studied , as well as the major design choices . Rigorous research design s such as the one described here are necessary to determine whether performance-based payment arrangements such as financial incentives result in meaningful quality improvements . Trial Registration http://www . clinical BACKGROUND The pharmaceutical care approach serves as a model for medication review , involving collaboration between GPs , pharmacists , patients , and carers . Its use is advocated with older patients who are typically prescribed several drugs . However , it has yet to be thoroughly evaluated . AIM To estimate the effectiveness of pharmaceutical care for older people , shared between GPs and community pharmacists in the UK , relative to usual care . DESIGN OF STUDY Multiple interrupted time-series design in five primary care trusts which implemented pharmaceutical care at 2-month intervals in r and om order . Patients acted as their own controls , and were followed over 3 years including their 12 months ' participation in pharmaceutical care . SETTING In 2002 , 760 patients , aged > or = 75 years , were recruited from 24 general practice s in East and North Yorkshire . Sixty-two community pharmacies also took part . A total of 551 participants completed the study . METHOD Pharmaceutical care was undertaken by community pharmacists who interviewed patients , developed and implemented pharmaceutical care plans together with patients ' GPs , and thereafter undertook monthly medication review s. Pharmacists and GPs attended training before the intervention . Outcome measures were the UK Medication Appropriateness Index , the Short Form-36 Health Survey ( SF-36 ) , and serious adverse events . RESULTS The intervention did not lead to any statistically significant change in the appropriateness of prescribing or health outcomes . Although the mental component of the SF-36 decreased as study participants become older , this trend was not affected by pharmaceutical care . CONCLUSION The RESPECT model of pharmaceutical care ( R and omised Evaluation of Shared Prescribing for Elderly people in the Community over Time ) shared between community pharmacists and GPs did not significantly change the appropriateness of prescribing or quality of life in older patients Abstract Objective To compare the results of a r and omised and an observational evaluation of the same policy that restricted reimbursement for nebulised respiratory medications in adult patients in a community setting . Design s Cluster r and omised controlled trial and observational time series with historical controls . Setting Pharmacare , the government funded drug benefits plan for elderly people and patients receiving social assistance in British Columbia , Canada . Participants In the r and omised controlled trial 104 clusters of medical practice s , pair matched by geography and approximately by practice size , were r and omised to the intervention group ( 449 patients affected by the policy on 1 March 1999 ) , and the control group ( offered a six month exemption , affecting 386 patients ) . The observational analysis included all Pharmacare beneficiaries ( excluding the 386 exempt patients ) who had used any nebulised drugs six months before the policy ( 4624 patients ) . Intervention Pharmacare restricted reimbursement for nebulised bronchodilators , steroids , and cromoglycate to patients whose doctors applied for an individual patient 's exemption , giving an appropriate clinical reason . Main outcome measures Number of contacts with doctors and services , emergency admissions to hospital , and utilisation of and expenditure for respiratory drugs in data bases of British Columbia 's Ministry of Health . Results Contacts with doctors or emergency admissions to hospital did not increase in association with the restriction , regardless of the analytical approach . In the observational analysis , we found a reduction of $ C24 per patient month in all nebulised drug use ( 95 % confidence interval 19 to 29 ) and an increase of $ C3 per patient month in all expenditure for inhalers ( 1.4 to 4.5 ) . The r and omised evaluation found savings of $ C8 per patient month for nebulisers ( P = 0.24 ) and no increase in spending on inhalers ( P = 0.79 ) . Correcting for 60 % non-compliance by exempt doctors in a sensitivity analysis yielded similar results as the observational evaluation . Conclusions Observational as well as r and omised analyses found moderate net savings and no increase in unintended healthcare outcomes after restricting reimbursement for nebulised respiratory drugs . R and omised policy trials are feasible and , if carefully implemented , likely to be concordant with observational evaluations Background While integrated health care system has been proved an effective way to help improving patient health and system efficiency , the exact behaviour model and motivation approach are not so clear in poor rural areas where health human re sources and continuous service provision are urgently needed . To gather solid evidence , we initiated a comprehensive intervention project in Qianjiang District , southwest part of rural China in 2012 . And after one-year 's pilot , we developed an intervention package of team service , comprehensive pathway and prospect ive- and performance-based payment system . Methods To testify the potential influence of payment interventions , we use clustered r and omised controlled trial , 60 clusters are grouped into two treatment groups and one control group to compare the time and group differences . Difference-in-differences model and structural equation modelling will be used to analyse the intervention effects and pathway . The outcomes are : quality of care , disease burden , supplier cooperative behaviour and patient utilisation behaviour and system efficiency . Repeated multivariate variance analysis will be used to statistically examine the outcome differences . Discussion This is the first trial of its kind to prove the effects and efficiency of integrated care . Though we adopted r and omised controlled trial to gather the highest rank of evidence , still the fully r and omisation was hard to realise in health policy reform experiment . To compensate , the design er should take efforts on control for the potential confounders as much as possible . With this trial , we assume the effects will come from : ( 1 ) improvement on the quality of life through risk factors control and lifestyles change on patient 's behaviours ; ( 2 ) improvement on quality of care through continuous care and coordinated supplier behaviours ; ( 3 ) improvement on the system efficiency through active interaction between suppliers and patients . Conclusion The integrated care system needs collaborative work from different levels of caregivers . So it is extremely important to consider the supplier cooperative behaviour . In this trial , we introduced payment system to help the delivery system integration through providing financial incentives to motivate people to play their roles . Also , the multidisciplinary team , the multi-institutional pathway and system global budget and pay-for-performance payment system could afford as a solution PURPOSE In this study , we sought to 1 ) describe elements of the financial and quality -of-life burden of dysfunctional uterine bleeding ( DUB ) from the perspective of women who agreed to obtain surgical treatment ; 2 ) explore associations between DUB symptom characteristics and the financial and quality -of-life burden ; 3 ) estimate the annual dollar value of the financial burden ; and 4 ) estimate the most that could be spent on surgery to eliminate DUB symptoms for which medical treatment has been unsuccessful that would result in a $ 50,000/ quality -adjusted life-year incremental cost-effectiveness ratio . METHODS We collected baseline data on DUB symptoms and aspects of the financial and quality -of-life burden for 237 women agreeing to surgery for DUB in a r and omized trial comparing hysterectomy with endometrial ablation . Measures included out-of-pocket pharmaceutical expenditures , excess expenditures on pads or tampons , the value of time missed from paid work and home management activities , and health utility . We used chi2 and t tests to assess the statistical significance of associations between DUB characteristics and the financial and quality -of-life burden . The annual financial burden was estimated . RESULTS Pelvic pain and cramps were associated with activity limitations and tiredness was associated with a lower health utility . Excess pharmaceutical and pad and tampon costs were $ 333 per patient per year ( 95 % confidence interval [ CI ] , $ 263-$403 ) . Excess paid work and home management loss costs were $ 2,291 per patient per year ( 95 % CI , $ 1847-$2752 ) . Effective surgical treatment costing $ 40,000 would be cost-effective compared with unsuccessful medical treatment . CONCLUSION The financial and quality -of-life effects of DUB represent a substantial burden OBJECTIVES To review UK guidelines regarding the use of financial incentives for healthcare professionals to become involved in clinical trials , and to survey perceptions and current practice . DATA SOURCES Electronic data bases were search ed from inception to June 2006 . Interviews were held with NHS healthcare professionals , research managers from the pharmaceutical industry and members of the public . REVIEW METHODS From the search es , 634 identified studies were assessed for inclusion in the systematic review , but only three met the criteria for data extraction . Fifty-eight individuals were interviewed : 38 chief investigators , six non- research active clinicians , eight public and six pharmaceutical managers . Investigators were selected from those funded by the HTA Programme , the other by ' snowballing ' and personal contact . RESULTS The evidence from the literature was limited and inconclusive . In UK guidelines , the issues around payments to clinicians or patients were implied rather than stated , usually linked to discussion of conflict of interest and disclosure of any such conflicts . Developments in NHS research governance had led to increased transparency in all payments for research participation and for payments to be made to NHS Trusts rather than individual clinicians . While reimbursement of costs incurred by research was strongly supported by the interviewees , payments to incentivise recruitment were not . A code of practice was suggested for payments in publicly funded trials , which was closely linked to the principles of Good Clinical Practice in research . Factors such as interest in the topic , scope for patient benefit and good communication were considered more important than payment . Interviews with the general public indicated low levels of awareness of the existence of payments to clinicians linked to patient recruitment in trials , and unanimous support for full disclosure . Interviews with managers in the pharmaceutical industry showed greater familiarity with payments for research involvement . GPs were seen as the only group for whom scope existed for individual payments . Concerns were expressed by the pharmaceutical company interviewees at the rising cost of research and unnecessary bureaucracy . CONCLUSIONS The ethical stances outlined in Good Clinical Practice in research were widely endorsed by the three groups interviewed . These allow reasonable payments to clinicians , subject to disclosure of any possible conflicts of interest . The potential for incentivising clinicians to recruit was limited as any payments should be based on the cost of inputs and should not be made to individuals but to their host organisation . NHS professionals were concerned that payments could damage the quality of research and also considered full disclosure to patients as challenging . Patients and members of the public favoured full disclosure and payment of expenses to patients involved in research . Pharmaceutical company interviewees viewed payment to the NHS for all research activities as normal and highly regulated . They complained that the prices charged were high and so variable that they required benchmarking . Considerable scope exists for compiling data on the factors that help and hinder the progress of clinical trials and also for experimenting with different incentives to encourage involvement in clinical research . Further research should focus on improved reporting of those organisational aspects of trials that are known to affect recruitment ; retrospective analysis of the factors associated with different levels of recruitment to RCTs ; prospect i ve comparative research on trial recruitment ; qualitative research on participants ' experiences of being involved in different kinds of trials , and proposals to include within trials experiments with payments methods Pay-for-performance in health care holds promise as a policy lever to improve the quality and efficiency of care . Although the approach has become increasingly popular in developing countries in recent years , most policy design s do not permit the rigorous evaluation of its impact . Thus , evidence of its effect is limited . In collaboration with the government of Ningxia Province , a predominantly rural area in northwest China , we conducted a matched-pair cluster-r and omized experiment between 2009 and 2012 to evaluate the effects of capitation with pay-for-performance on  primary care providers ' antibiotic prescribing practice s , health spending , outpatient visit volume , and patient satisfaction . We found that the intervention led to a reduction of approximately 15 percent in antibiotic prescriptions and a small reduction in total spending per visit to village posts-essentially , community health clinics . We found no effect on other outcomes . Our results suggest that capitation with pay-for-performance can improve drug prescribing practice s by reducing overprescribing and inappropriate prescribing . Our study also shows that rigorous evaluations of health system interventions are feasible when conducted in close collaboration with the government OBJECTIVES To compare the health care and opportunity costs of three common health problems [ depressive disorders , reproductive tract infections ( RTIs ) and anaemia ] affecting women and their associated risks of catastrophic health expenditure ( defined a priori as out-of-pocket expenditure on health care exceeding 10 % of the total monthly household income ) . METHODS Cross-sectional survey of 2494 women who consented to participate , from a r and omly selected sample of 3000 women aged 18 - 50 , living in the catchment area of a primary health centre in Goa , India . Depressive disorders were diagnosed with the Revised Clinical Interview Schedule ; anaemia on the basis of a fingerprick sample of blood using the Haemocue system ; and RTI using PCR , culture and microscopy with vaginal or urine specimens . Economic consequences were measured using the Costs of Illness Schedule and the WHO Disability Assessment Schedule . Health provision costs were calculated using previously derived unit costs for services for the main types of health care provider . RESULTS Catastrophic health expenditure , defined a priori as > 10 % of total household income spent out of pocket on health in the previous month , was reported by 138 women ( 5.5 % ; CI : 4.7 - 6.5 % ) ; they were more likely to report economic difficulties , such as having gone hungry in the past 3 months because of lack of money ( OR 1.99 , CI 1.1 - 3.6 , P = 0.02 ) . Only depressive disorder was associated with significantly higher health care costs , lost time costs and risk of catastrophic health expenditure ( OR 2.66 , CI 1.6 - 4.4 , P < 0.001 , after adjustment for possible sociodemographic confounders and other physical health problems ) . There was a linear association between the psychological morbidity score ( arranged into quintile groups ) and the risk of catastrophic health expenditure ( adjusted ) . CONCLUSIONS If economic arguments were considered a key driver for global health policy , then depressive disorder should be considered a major health priority for women in developing countries PURPOSE Potentially inappropriate prescribing ( PIP ) is common in older people and can result in increased morbidity , adverse drug events , and hospitalizations . The OPTI-SCRIPT study ( Optimizing Prescribing for Older People in Primary Care , a cluster-r and omized controlled trial ) tested the effectiveness of a multifaceted intervention for reducing PIP in primary care . METHODS We conducted a cluster-r and omized controlled trial among 21 general practitioner practice s and 196 patients with PIP . Intervention participants received a complex , multifaceted intervention incorporating academic detailing ; review of medicines with web-based pharmaceutical treatment algorithms that provide recommended alternative-treatment options ; and tailored patient information leaflets . Control practice s delivered usual care and received simple , patient-level PIP feedback . Primary outcomes were the proportion of patients with PIP and the mean number of potentially inappropriate prescriptions . We performed intention-to-treat analysis using r and om-effects regression . RESULTS All 21 practice s and 190 patients were followed . At intervention completion , patients in the intervention group had significantly lower odds of having PIP than patients in the control group ( adjusted odds ratio = 0.32 ; 95 % CI , 0.15–0.70 ; P = .02 ) . The mean number of PIP drugs in the intervention group was 0.70 , compared with 1.18 in the control group ( P = .02 ) . The intervention group was almost one-third less likely than the control group to have PIP drugs at intervention completion , but this difference was not significant ( incidence rate ratio = 0.71 ; 95 % CI , 0.50–1.02 ; P = .49 ) . The intervention was effective in reducing proton pump inhibitor prescribing ( adjusted odds ratio = 0.30 ; 95 % CI , 0.14–0.68 ; P = .04 ) . CONCLUSIONS The OPTI-SCRIPT intervention incorporating academic detailing with a pharmacist , and a review of medicines with web-based pharmaceutical treatment algorithms , was effective in reducing PIP , particularly in modifying prescribing of proton pump inhibitors , the most commonly occurring PIP drugs nationally
Although financial incentives are considered an important element in strategies to change prescribing patterns , limited evidence of their effects can be found .
BACKGROUND The proportion of total healthcare expenditures spent on drugs has continued to grow in countries of all income categories .
Policy-makers are under pressure to control pharmaceutical expenditures without adversely affecting quality of care .
Financial incentives seeking to influence prescribers ' behaviour include budgetary arrangements at primary care and hospital setting s ( pharmaceutical budget caps or targets ) , financial rewards for target behaviours or outcomes ( pay for performance interventions ) and reduced benefit margin for prescribers based on medicine sales and prescriptions ( pharmaceutical reimbursement rate reduction policies ) .
This is the first up date of the original version of this review .
OBJECTIVES To determine the effects of pharmaceutical policies using financial incentives to influence prescribers ' practice s on drug use , healthcare utilisation , health outcomes and costs ( expenditures ) .