Problems of Administering Drugs by Continuous Infusion

A study of how often drugs were administered by continuous intravenous infusion to patients occupying 110 surgical and 50 medical beds showed that an average of 48 drug additions were made to intravenous fluids each week: 15% of these were of more than one drug and 15% were of drugs incompatible either with each other or with the infusion fluid. As a result of the survey an educational programme was developed to bring these problems to the attention of the staff concerned. After this programme a second survey showed only 18 additives had been given to patients occupying the same 160 beds and none of these were incompatible mixtures.     

Sleeping arrangements and mosquito net use among under-fives: results from the Uganda Demographic and Health Survey

Background

Private outlets are the main suppliers of uncomplicated malaria treatment in Africa. However, they are so numerous that they are difficult for governments to influence and regulate. This study's objective was to evaluate a low-cost outreach education (vendor-to-vendor) programme to improve the private sector's compliance with malaria guidelines in Bungoma district, Kenya. The cornerstone of the programme was the district's training of 73 wholesalers who were equipped with customized job aids for distribution to small retailers.

Methods

Six months after training the wholesalers, the programme was evaluated using mystery shoppers. The shoppers posed as caretakers of sick children needing medication at 252 drug outlets. Afterwards, supervisors assessed the outlets' knowledge, drug stocks, and prices.

Results

The intervention seems to have had a significant impact on stocking patterns, malaria knowledge and prescribing practices of shops/kiosks, but not consistently on other types of outlets. About 32% of shops receiving job aids prescribed to mystery shoppers the approved first-line drug, sulfadoxine-pyremethamine, as compared to only 3% of the control shops. In the first six months, it is estimated that 500 outlets were reached, at a cost of about $8000.

Conclusions

Changing private sector knowledge and practices is widely acknowledged to be slow and difficult. The vendor-to-vendor programme seems a feasible district-level strategy for achieving significant improvements in knowledge and practices of shops/kiosks. However, alternate strategies will be needed to influence pharmacies and clinics. Overall, the impact will be only moderate unless national policies and programmes are also introduced.     

Hospital pharmacy committees in England: Their structure,function, and development.

A total of 150 chief and group chief pharmacists in England took part in a survey of the structure and role of pharmacy committees in hospitals. Just over half of the hospitals had such a committee. About two-thirds of these dealt only with pharmacy matters and one-third dealt also with other matters. The number of new committees set up increased slowly until 1967 and then showed a sharp rise. Their terms of reference, membership, and manner of appointment varied greatly. Among subjects dealt with the cost of drugs and the introduction of new prescribing sheets were prominent. Many of the respondents believed that the work of the committees, often with the help of smaller, more specialized groups, had significantly improved various aspects of the local supply and use of drugs.     

Improving benzodiazepine prescribing in family practice through review and education.

Indications for and dosages of four commonly prescribed benzodiazepines were recorded at a family medicine centre with the aid of a computerized data collection system. Four guidelines were then developed for appropriate prescribing of these drugs: (a) benzodiazepines should be used less frequently with increasing age; (b) short-acting drugs are preferable to long-acting drugs; (c) patients 65 years of age and over should receive half the daily dose prescribed for younger patients; and (d) use of these drugs for more than 1 month should be discouraged. After a year''s observation it was evident that none of the guidelines were being followed. The 30 physicians in the practice were then informed of the findings by an educational program. Another 6 months of observation showed a reduction in the prescribing of benzodiazepines to patients 65 years of age and over, a significant shift to the use of short-acting benzodiazepines, and some reduction in the daily dose and duration of administration of diazepam. Thus, such a review of drug prescribing in family practice can be a practical and effective method of improving prescribing patterns.     

Effectiveness and economic evaluation of a nurse delivered home exercise programme to prevent falls. 2: Controlled trial in multiple centres

ObjectivesTo assess the effectiveness of trained nurses based in general practices individually prescribing a home exercise programme to reduce falls and injuries in elderly people and to estimate the cost effectiveness of the programme.DesignControlled trial with one year''s follow up.Setting32 general practices in seven southern New Zealand centres.Participants450 women and men aged 80 years and older.Intervention330 participants received the exercise programme (exercise centres) and 120 received usual care (control centres); 87% (371 of 426) completed the trial.ResultsFalls were reduced by 30% in the exercise centres (incidence rate ratio 0.70, 95% confidence interval 0.59 to 0.84). The programme was equally effective in men and women. The programme cost $NZ418 (£121) (at 1998 prices) per person to deliver for one year or $NZ1519 (£441) per fall prevented. Fewer participants had falls resulting in injuries, but there was no difference in the number who had serious injuries and no difference in hospital costs resulting from falls in exercise centres compared with control centres.ConclusionsAn individually tailored exercise programme, delivered by trained nurses from within general practices, was effective in reducing falls in three different centres. This strategy should be combined with other successful interventions to form part of home programmes to prevent falls in elderly people.

What is already known on this topic

One half of those aged 80 years and older will fall in any one year, often with serious health and social consequencesAn exercise programme delivered by a physiotherapist or trained district nurse was successful in reducing falls and moderate injuries in elderly people

What this study adds

An exercise programme to prevent falls in elderly people can be delivered safely and effectively by trained nurses in general practicesThe nurses obtained results that were consistent with the physiotherapist in the research setting and the district nurse in the accompanying paper     

Factors associated with the use of evidence-based therapies after discharge among elderly patients with myocardial infarction

Background

In an accompanying article, we report moderate between-hospital variation in the postdischarge use of β-blockers, angiotensin-modifying drugs and statins by elderly patients who had been admitted to hospital with acute myocardial infarction. Our objective was to identify the characteristics of patients, physicians, hospitals and communities associated with differences in the use of these medications after discharge.

Methods

For this retrospective, population-based cohort study, we used linked administrative databases. We examined data for all patients aged 65 years or older who were discharged from hospital in 2005/06 with a diagnosis of myocardial infarction. We determined the effect of patient, physician, hospital and community characteristics on the rate of postdischarge medication use.

Results

Increasing patient age was associated with lower postdischarge use of medications. The odds ratios (ORs) for a 1-year increase in age were 0.98 (95% confidence interval [CI] 0.97–0.99) for β-blockers, 0.97 (95% CI 0.97–0.98) for angiotensin-converting-enzyme inhibitors and angiotensin-receptor blockers and 0.94 (95% CI 0.93–0.95) for statins. Having a general or family practitioner, a general internist or a physician of another specialty as the attending physician, relative to having a cardiologist, was associated with lower postdischarge use of β-blockers, angiotensin-modifying agents and statins (ORs ranging from 0.46 to 0.82). Having an attending physician with 29 or more years experience, relative to having a physician who had graduated within the past 15 years, was associated with lower use of β-blockers (OR 0.71, 95% CI 0.60–0.84) and statins (OR 0.81, 95% CI 0.67–0.97).

Interpretation

Patients who received care from noncardiologists and physicians with at least 29 years of experience had substantially lower use of evidence-based drug therapies after discharge. Dissemination strategies should be devised to improve the prescribing of evidence-based medications by these physicians.The use of medications such as acetylsalicylic acid (ASA), β-blockers, angiotensin-modifying drugs (angiotensin-converting-enzyme [ACE] inhibitors and angiotensin-receptor blockers) and statins is a mainstay of secondary prevention of myocardial infarction. In a companion study published in this issue of CMAJ, we report substantial increases in the use of evidence-based drug therapies after discharge among elderly patients with myocardial infarction over a 14-year period.¹ However, despite temporal improvements, the prescribing of evidence-based drug therapies differed among hospitals in 2005.Studies from the late 1980s to the mid-1990s showed that the prescribing of evidence-based drug therapies was influenced by patient characteristics.^2–6 However, the extent to which postdischarge prescribing is influenced by patient, physician, hospital and community characteristics has not been extensively explored.Our objective was to identify patient, physician, hospital and community characteristics associated with the use of of evidence-based drug therapies after discharge among patients with myocardial infarction.     

Prescribing of psychoactive drugs for chronically ill elderly patients.

The prescribing of psychoactive drugs for 1431 chronically ill elderly patients being assessed for long-term institutional or community care was surveyed. Psychoactive drugs had been prescribed for about one quarter of the patients; benzodiazepines were the most frequently prescribed group. Judging from the extensive prescribing of flurazepam and chloral hydrate, commonly used hypnotics, the main reason psychoactive drugs were prescribed was to provide night-time sedation. Antidepressants and drugs promoted as useful in improving cognitive function were infrequently prescribed. Commendable prescribing practices included the infrequent use of "cerebral vasodilators" and barbiturates. Questionable prescribing practices included the infrequent use of tricyclic antidepressants in severely depressed patients and the use of tranquilizers in patients described by their attending physician as markedly or extremely withdrawn.     

Schistosomiais and Soil-Transmitted Helminth Control in Niger: Cost Effectiveness of School Based and Community Distributed Mass Drug Administration

Background

In 2004 Niger established a large scale schistosomiasis and soil-transmitted helminths control programme targeting children aged 5–14 years and adults. In two years 4.3 million treatments were delivered in 40 districts using school based and community distribution.

Method and Findings

Four districts were surveyed in 2006 to estimate the economic cost per district, per treatment and per schistosomiasis infection averted. The study compares the costs of treatment at start up and in a subsequent year, identifies the allocation of costs by activity, input and organisation, and assesses the cost of treatment. The cost of delivery provided by teachers is compared to cost of delivery by community distributers (CDD).The total economic cost of the programme including programmatic, national and local government costs and international support in four study districts, over two years, was US$ 456,718; an economic cost/treatment of $0.58. The full economic delivery cost of school based treatment in 2005/06 was $0.76, and for community distribution was $0.46. Including only the programme costs the figures are $0.47 and $0.41 respectively. Differences at sub-district are more marked. This is partly explained by the fact that a CDD treats 5.8 people for every one treated in school.The range in cost effectiveness for both direct and direct and indirect treatments is quantified and the need to develop and refine such estimates is emphasised.

Conclusions

The relative cost effectiveness of school and community delivery differs by country according to the composition of the population treated, the numbers targeted and treated at school and in the community, the cost and frequency of training teachers and CDDs. Options analysis of technical and implementation alternatives including a financial analysis should form part of the programme design process.     

Postgraduate education in therapeutics: experience in Merseyside.

A teaching programme in therapeutics for general practitioners in Merseyside, which was led by a group of clinical pharmacologists, had as its principal aim to emphasise the importance of rational drug prescribing. The course comprised 15 sessions restricted to 25 GPs, and the topics were suggested by both the organisers and the GPs. Though each session was introduced by a clinical pharmacologist, the emphasis was an open discussion and exchange of views. This programme may serve as a pattern for other centres.     

Effectiveness and economic evaluation of a nurse delivered home exercise programme to prevent falls. 1: Randomised controlled trial

ObjectivesTo assess the effectiveness of a trained district nurse individually prescribing a home based exercise programme to reduce falls and injuries in elderly people and to estimate the cost effectiveness of the programme.DesignRandomised controlled trial with one year''s follow up.SettingCommunity health service at a New Zealand hospital.Participants240 women and men aged 75 years and older.Intervention121 participants received the exercise programme (exercise group) and 119 received usual care (control group); 90% (211 of 233) completed the trial.ResultsFalls were reduced by 46% (incidence rate ratio 0.54, 95% confidence interval 0.32 to 0.90). Five hospital admissions were due to injuries caused by falls in the control group and none in the exercise group. The programme cost $NZ1803 (£523) (at 1998 prices) per fall prevented for delivering the programme and $NZ155 per fall prevented when hospital costs averted were considered.ConclusionA home exercise programme, previously shown to be successful when delivered by a physiotherapist, was also effective in reducing falls when delivered by a trained nurse from within a home health service. Serious injuries and hospital admissions due to falls were also reduced. The programme was cost effective in participants aged 80 years and older compared with younger participants.

What is already known on this topic

Falls are the costliest type of injury among elderly people, and the healthcare costs increase with frequency of falls and severity of injuriesAn exercise programme delivered by a physiotherapist was successful in reducing falls and moderate injuries in elderly people

What this study adds

An exercise programme to prevent falls in elderly people worked well when delivered by a district nurse from a home health service in the suburbs of a large cityResearchers, public health administrators, and health practitioners can work together to benefit elderly people in the community     

Market penetration of new drugs in one United Kingdom region: implications for general practitioners and administrators.

OBJECTIVE--To determine the use of new drugs in one United Kingdom region. DESIGN--Examination of data on prescribing of angiotensin converting enzyme inhibitors, new broad spectrum antibiotics, and H2 receptor antagonists. Calculation of number of defined daily doses prescribed each month. SETTING--All general practices in Northern Ireland. MAIN OUTCOME MEASURES--Drug use index and market share of each drug. RESULTS--During 1988-91 prescribing of angiotensin converting enzyme inhibitors increased by 126%, of H2 receptor antagonists by 46%, and of new antibiotics by 207%. The first drug on the market usually retained the largest market share. Use of oral antibiotics increased threefold irrespective of the reporting policy of the general practitioners'' local laboratory. CONCLUSIONS--The increase in prescribing of these drugs seems to be greater than can be accounted for by an increase in patients with specific indications for these drugs. This suggests that the profession has not instituted effective checks to ensure that the legitimate promotion of new products does not lead to inappropriate and wasteful use.