Our institution achieved a significant increase in standard pregnancy screening in adolescent girls receiving intravenous cyclophosphamide. The interventions most valuable in increasing screening rates were updating electronic order sets, educating staff, and physician engagement in the Maintenance of Certification program.
Expenditures for prescription drugs continue to increase, prompting insurers and health systems to adopt formulary or coverage policies restricting the use of more expensive drugs. Those establishing formulary policies face a complex array of claims regarding differences in efficacy, safety, treatment cost, or cost-effectiveness. We describe and illustrate 5 specific principles for applying research evidence to formulary decisions: (1) Experimental data should take precedence over models or simulations, and assumptions of such models should be carefully examined. (2) Morbidity or mortality outcomes should take precedence over surrogate or intermediate outcomes. (3) Claims for advantages of new treatments should consider the full range of alternatives rather than those selected by industry. (4) Variation in effects across individuals or subgroups argue against restrictions on first-line treatment, but only if those differences are predictable. (5) Variation in effects argues against requiring changes in ongoing treatment. We also discuss how economic incentives are likely to influence selection of research questions, especially research related to drug-gene interactions and to identifying new indications for existing drugs.
Background: Among medically underserved immigrant parents, access to nonprescription medicines for home treatment of minor childhood illnesses may be limited by scarce financial resources or language barriers. Objectives: To design and implement a new clinical service for an urban ambulatory pediatric clinic with a large immigrant population that allows pharmacists to evaluate and to treat children and adolescents aged 6 months to 19 years with minor acute illnesses and to provide bilingual patient education materials. Methods: We developed protocols and encounter forms for pharmacist evaluation of 5 pediatric conditions: cough/ cold, fever, diaper rash, vomiting/diarrhea, and head lice. We published bilingual patient education materials for these conditions in 8 commonly spoken languages. We assessed safety by throughly reviewing the medical records of all patients who returned within 1 week of a pharmacy encounter and by asking parents in a telephone survey to compare services received through the pharmacy and the acute care clinic for treatment of the common cold. Results: During the first year of this pilot program, 191 patients were evaluated and treated, 145 (76%) for cough/ cold. Seventy percent of the patients were immigrants. No unexpected or adverse outcomes were detected, although occasional deviations from established protocols were noted. Parent satisfaction with the pharmacy service was high, and similar to that received through the standard acute care clinic. Patients evaluated by pharmacists were more likely to be attended to promptly (Ͻ15minute wait) and were more likely to receive written information than patients evaluated by physicians for similar conditions. Conclusions: Pharmacist evaluation and treatment of minor pediatric illnesses seems to be both safe and well accepted. Further studies are needed to evaluate the costeffectiveness of this service in diverse settings. In states that allow pharmacists to have prescriptive authority, pharmacy-based evaluation and treatment may improve access to care for children with minor illnesses.
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