New antibiotics have been introduced over the years to overcome drug resistance, but even these antibiotics have lost their efficacy against important Gram-negative bacteria with resistance to these drugs increasing rapidly across Europe and adjacent regions. We surveyed 800 hospital-based physicians in 4 European countries and Russia to assess their level of ARGN awareness and perceived ability to manage this growing and serious problem.

Background: Tamoxifen is a selective estrogen receptor modulator (SERM) commonly used to treat and prevent estrogen-receptor-positive (ERP) breast cancer. However, despite its established efficacy, recent studies indicate that 1 in 2 patients will discontinue use of the drug prior to completing the recommended five-year treatment cycle. The alleviation of unpleasant side effects through personalized targeting of tamoxifen dose and, as appropriate, concomitant administration of a CYP2D6 inhibitor could increase adherence and increase the likelihood that patients will receive the amount of the drug needed to protect them against disease onset and/or recurrence. Materials and Methods: A retrospective cohort study was implemented to assess whether overlapping therapy with highdose tamoxifen and CYP2D6 inhibitors influence medication adherence during the first 540 days of therapy. Subjects (N = 17,242) were identified in an integrated medical and pharmacy claims database and selected for inclusion in the study if they 1) filled a new tamoxifen prescription between 7/1/2008 and 6/30/2009 and 2) were continuously eligible to receive pharmacy benefits during the 6 months preceding and 12 months after initiation of therapy. Eligible participants were then cross-classified according to tamoxifen dose (NORMAL, HIGH) and CYP2D6 inhibitor status (NO, YES), and a Cox regression model was fitted to the data to obtain covariate-adjusted hazard ratios (HR) and 95% confidence intervals for each treatment combination relative to the HIGH/NO group. Results: The lowest and highest hazard ratios were observed in the NORMAL/YES [HR = 0.924 (0.88, 0.97)] and HIGH/NO [HR = 2.33 (2.07, 2.62)] categories. Moreover, the risk of discontinuation was significantly reduced when high-dose tamoxifen was administered in concert with a CYP2D6 inhibitor [HR = 1.31 (0.953, 1.802)]. Discussion: These study suggests that joint treatment with high-dose tamoxifen and a CYP2D6 inhibitor may improve tamoxifen adherence in breast cancer patients. The findings also highlight the need for 1) education and research regarding tamoxifen dosing and 2) careful consideration for when–and under what circumstances–concomitant medications should be prescribed to enhance patient tolerance of tamoxifen-related negative symptoms. Citation Information: Cancer Res 2010;70(24 Suppl):Abstract nr P4-02-15.

STUDY OBJECTIVE:To measure the rate of dispensing errors and to identify the types and sources of dispensing errors in a highly automated mail-service pharmacy practice.DESIGN:Descriptive analysis of a random sample of completed prescriptions.SETTING:A high-volume mail-service pharmacy practice comprising a network of prescription processing and dispensing pharmacies in the United States.MEASUREMENTS AND MAIN RESULTS:During September and October 2003, new and refill prescriptions were retrieved before shipping and evaluated for dispensing accuracy. Container contents were compared against the container label, and the label record was compared against the original prescription order. The overall dispensing error rate was 0.075% (16 dispensing errors among 21,252 prescriptions, 95% confidence interval 0.043-0.122). Fourteen errors involved incomplete or incorrect directions on the final label. All dispensing errors were associated with the initial stages of prescription processing (including order entry); no errors were associated with the mechanical stages of product dispensing.CONCLUSION:A highly automated mail-service pharmacy can achieve a dispensing error rate of less than 1 error/1000 prescriptions, which is substantially lower than the rates reported for retail pharmacies. A high degree of automation in the mechanical aspects of dispensing appears to be a key factor in achieving this high dispensing accuracy.

Objectives: To review the definitions and methods for measuring medication persistency, and to propose a uniform definition of and calculation for persistency using pharmacy claims data.Study Design: Literature review.Methods: A MEDLINE search (1966 to present) was performed to identify articles detailing a definition or method of persistency measurement based on automated pharmacy data. Articles were screened for relevance by title and abstract. References from identified articles were used to expand the search results.Results: The concept behind medication persistency measurement is to capture the amount of time that an individual remains on chronic drug therapy. The methods to calculate medication persistency can be classified into 1 of 3 categories: (I) Persistency as a function of the medication possession ratio; (2) persistency as a function of medication availability at a fixed point in time; and (3) persistency as a function of the gaps between refills.Conclusions: The common goal of all persistency measures should be to reflect the continuity of medication usage and to capture the timeliness and the frequency of refilling. The measurement of persistency as a function of the gaps between refills provides the best assessment of refill compliance across a variety of medication and disease states and lends itself to the well-established measurements of survival analysis.

Background and objective: In day-to-day practice, asthma treatment and self-management often fall short of the objectives defined by clinical practice guidelines. The objective of this study was to determine whether a population-based asthma disease management program, using broad-based educational interventions, can have a favorable impact on physician and patient adherence to guidelines-based care.Methods: A longitudinal, before-and-after design was used to evaluate program impacts on pharmacotherapy and health status. Patients with asthma (n = 35 450) were enrolled in the program from September 2000 through to June 2001. Patients were identified for the study based on a 12-month retrospective analysis of pharmacy claims. Patients were members of prescription benefit plans managed by Medco Health and were aged 5 years and older. Patients in the intervention group received asthma education materials during the 12-month period following enrollment. The materials emphasized guidelines-based principles of asthma pharmacotherapy, self-management, trigger avoidance and patient-physician partnership. Physicians received guidelines-based flow sheets to facilitate therapy tracking, and pharmacotherapy review. Asthma drug utilization was measured during the 12-month period prior to enrollment and the 12-month period following enrollment. Utilization data on controller and reliever medications were derived from a pharmacy claims database. Drug utilization changes for the intervention group were compared with those for matched controls. A health survey was conducted on a random sample of program participants at enrollment and at 12-month follow-up. The health survey included questions on asthma-related quality of life (QOL), medical utilization, productivity, and self-management skills.Main outcome measures and results: The percentage of patients who started controller therapy during the study period was significantly higher for the intervention group than the control group (20.7% versus 18.1%, p < 0.001). The controller prescription fill rate increased significantly in the intervention group compared with controls (p < 0.0001); the increase was primarily driven by increased refill rates for patients already using controllers. Reliever prescription fill rates decreased for both the intervention group and controls. Program participants reported significant improvements in asthma-related QOL (p < 0.05) and self-management skills. Self-reported medical utilization decreased for office visits (p < 0.05) and emergency room visits (p < 0.01).Conclusions: A population-based asthma disease management program can improve controller prescribing rates (new therapy starts), controller adherence rates (refill persistency), and self-management skills. These changes in physician and patient behavior help close the gaps between guidelines and practice in asthma therapy.

PURPOSE: National Asthma Education and Prevention Program (NAEPP) guidelines recommend therapy based on structured severity stratifications for each patient, and written action plans with self-monitoring of peak flows. Nevertheless, many patients do not receive guideline-based care. This study surveyed physicians treating asthma patients to identify significant differences in guidelines-based care across specialties.

OBJECTIVEThe St. George's Respiratory Questionnaire (SGRQ) has been validated and widely used in assessing quality of life among patients with chronic obstructive pulmonary disease (COPD), but it is time-consuming and complicated to score. A more concise instrument, the Airways Questionnaire (AQ), was developed to measure quality of life (QoL) among patients with asthma and COPD. The shorter version of this instrument has 20 items (AQ20) and the longer version has 30 items (AQ30). The purpose of this study was to determine the relationship between QoL scores measured by the AQ20/30 or the SGRQ scale and utilization of health-care services by COPD patients and to evaluate the comparative advantage of any one of these instruments in measuring the QoL of COPD patients.METHODSResults from a survey of 1000 patients participating in a pilot COPD health management program were used for this analysis. A total of 303 patients completed both the AQ20/30 and the SGRQ questionnaires. Logistic regression models were used to analyze the relationship between utilization of health care services and QoL scores while controlling for a set of covariates. Spearman's rank correlation was used to determine whether the AQ30 and the SGRQ scores for symptoms, activity, and impact, and the overall scores were correlated.RESULTSThe regression results demonstrate that there is a strong relationship between quality-of-life scores and health-care utilization variables. Moreover, the degree of association between the AQ20/30 scores and utilization variables and the SGRQ and utilization variables are comparable. Both the AQ20 and the AQ30 were highly correlated with the overall SGRQ score and with symptoms, activity, and impact component scores.CONCLUSIONThe AQ20/30 and the SGRQ scores are comparable in terms of measuring QoL in COPD patients and are equally useful in determining the association between utilization of health-care services and QoL.

OBJECTIVE To examine baseline renal screening practices and the effect of nurse case management of patients with diabetes in a group model health maintenance organization (HMO). RESEARCH DESIGN AND METHODS We performed both 1-year retrospective and 1-year prospective studies of renal assessment practices and ACE inhibitor usage in a cohort of 133 diabetic patients enrolled in a randomized controlled trial of a diabetes nurse case management program in a group model HMO. In accordance with American Diabetes Association recommendations, urine dipstick and quantitative protein and microalbuminuria testing rates were calculated. RESULTS At baseline, 77% of patients were screened for proteinuria with dipsticks or had quantitative urine testing. Of patients with negative dipstick findings, 30% had appropriate quantitative protein or microalbumin follow-up at baseline. Baseline ACE inhibitor usage was associated with decreased follow-up testing (relative risk = 0.47). Nurse case management was associated with increased quantitative protein or or microalbumin testing and increased follow-up testing (relative risk = 1.65 and 1.60, respectively). CONCLUSIONS We found a higher degree of adherence to recommendations for renal testing than has been reported previously. Nurse case management intervention further increased renal screening rates. The inverse association between ACE inhibitor usage and microalbumin testing highlights a potentially ambiguous area of current clinical pathways.