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Biomedical subjects

D M Kirking

Publications and source records attributed to D M Kirking.

At least 19 recordsLinked to original sources
PubMed2002

Relationship between patient and disease characteristics, and health-related quality of life in adults with asthma.

The purpose of this study was to examine relationships between patient- and disease-related variables and health-related quality of life (HQL). This cross-sectional study surveyed adults with asthma enrolled in a managed care organization (MCO). Data were obtained from a mailed questionnaire and the MCO's patient and claims databases. The Asthma Quality of Life Questionnaire (AQLQ) and the SF-36 instruments were used. The behavioral Model of Health Services Utilization was used to characterize independent variables and their relationships to HQL. Independent variables included predisposing (age, gender, education, race, number of comorbidities, years with asthma, social support, health-belief questions); enabling (income, number of metered dose inhaler (MDI) instructors, perceived inconvenience of accessing the physician); and illness level (perceived and symptom-derived asthma severity). Multivariate linear regression models were developed to examine the relationships between the independent variables and the domain and summary scores of the AQLQ and the SF-36. The survey response rate was 63% (n=603). for the AQLQ, symptom-derived severity perceived severity education level, and the health-belief factor Barriers were significant in all five models. Symptom-derived severity had consistently higher standardized regression coefficients than perceived severity Barriers had the highest coefficient in all but the Symptoms domain model. Number of Comorbidities was significant in all eight domain and two summary score SF-36 models. Symptom-derived and/or perceived severity were also significant in all but the Mental Health domain model. Other frequently significant variables included the health-belief factor Barriers and Yearly Household Income. When assessing HQL of a population, such as this group of patients with asthma, one must consider patient and disease variables that may influence the results.

Adult↗
PubMed2001

The effect of insurance coverage changes on drug utilization in HIV disease.

BACKGROUND: Insurance coverage facilitates access to life-saving medications for many patients with HIV disease. Thus, the effects of insurance coverage changes, such as the gain or loss of coverage, may be important in explaining patient access and adherence to the medications used in the treatment of HIV disease. OBJECTIVES: The study's objective was to examine whether changes in health insurance coverage affect rates of prescription drug use by patients with HIV disease. METHODS: Data were ascertained from adults participating in a series of up to six interviews as part of the AIDS Costs and Services Utilization Survey (ACSUS). ACSUS was an 18-month panel survey of patients in care for HIV/AIDS at 26 sites located in 10 U.S. cities. Poisson regression analyses with generalized estimating equations were conducted to determine the effects of demographic and socioeconomic variables on the acquisition rate of antiretrovirals, antipneumocystics, and antidepressants. The analytic sample consisted of 1566 respondents who provided 6518 interviews. RESULTS: Although changes in insurance coverage were common, complete loss of insurance was reported in only 1.5% of the interviews whereas gaining insurance was reported in 3.3% of interviews. Having no coverage was associated with significantly lower rates of antiretroviral (rate ratio [RR], 0.73), antipneumocystic (RR, 0.58) and antidepressant use (RR, 0.31). Gaining insurance coverage was associated with lower antiretroviral (RR, 0.75) and antipneumocystic (RR, 0.70) use whereas losing insurance was associated with lower antiretroviral use (RR, 0.58). In multivariate analyses, these associations remained. CONCLUSIONS: Changes in health insurance coverage are associated with lower rates of drug use for some medications used by patients with HIV disease.

Adult↗
PubMed2001

Compliance from self-reported versus pharmacy claims data with metered-dose inhalers.

OBJECTIVE: To determine how well self-reported compliance with metered-dose inhalers (MDIs) agrees with compliance determined from pharmacy claims data. Additional analyses were conducted to establish phychmetric properties of the questionnaire. METHODS: A cross-sectional survey was performed of all adult enrollees with asthma of a managed care organization. The overall return rate was 63.4% (696/1098). Patents with persistent asthma and at least one prescription claim for a controller MDI during the four months preceding the survey were included. Pharmacy claims data were used to calculate a compliance ratio. Self-reported compliance was based on a four-item questionnaire. The primary end points were the percent-agreement and the overall correlation between the two measures. The questionnaire's internal reliability and construct validity were assessed using Cronbach's alpha and Pearson's correlations, respectively. Mean item response scores for compliant patients were compared with scores of noncompliant patients using the Student's t-test. RESULTS: One hundred questionnaire respondents met the study criteria. The mean +/- SD compliance ratio was 0.52+/-0.27, the mean +/- SD self-reported compliance score was 4.07+/-1.0. The overall percent agreement and correlation between self-reported compliance score and the compliance ratio were 75.5% and r = 0.348 (p = 0.01), respectively. The percent agreement was highest (85%) when noncompliant patients (by compliance ratio <0.8) reported being noncompliant (questionnaire score <5). Cronbach's alpha was 0.86. CONCLUSIONS: This study demonstrated a moderate correlation between self-reported asthma compliance and the compliance ratio determined using claims data. The questionnaire may be useful as a screening tool to detect noncompliant behavior in populations or individual patients with asthma.

Adult↗
PubMed2001

Decomposing pharmaceutical cost growth in different types of health plans.

OBJECTIVE: To decompose pharmaceutical spending growth into price and quantity components and to compare growth across different types of health plans. STUDY DESIGN: Retrospective analysis of pharmaceutical claims for active employees of a large national employer from 1996 to 1998, who were enrolled in traditional fee-for-service plans, health maintenance organizations (HMOs), and preferred provider organizations. OUTCOME MEASURES: Outcomes measures included total cost growth, price growth, and quantity growth. Quantity growth was divided into growth in use of existing products and in use of newly introduced products. For existing products, quantity growth was further decomposed into growth in the number of prescriptions and change in the mix of prescriptions. RESULTS: During the study period, HMOs had the greatest cost growth. This differential cost growth was largely attributable to changes in utilization as opposed to changes in prices, which were similar among types of health plans. Introduction of new products contributed 15 to 20 percentage points to cost growth in each setting. Differences in cost growth were largely attributed to differences in the growth rate of spending on existing products. For existing products, the impact of increases in the number of prescriptions was much greater in the HMOs, while the impact of changes in the mix of prescriptions was only mildly greater in the HMOs. CONCLUSIONS: Pharmaceutical cost growth was largely attributable to changes in utilization as opposed to changes in prices. Changes in utilization patterns were complex and differed across types of health plans.

Adolescent↗
PubMed2000

Pharmacists' understanding of patient education on metered-dose inhaler technique.

OBJECTIVE: To assess pharmacists' attitudes, beliefs, and knowledge about assessing and educating patients regarding metered-dose inhaler (MDI) technique; to determine frequency of MDI assessment and teaching behavior; and to assess the effect of an asthma pharmaceutical care educational program on the same variables six months later. DESIGN: Questionnaire completed before and six months after the educational intervention. SETTING: Pharmacies based in clinics owned by a healthcare system located in communities of a large metropolitan area. MAIN OUTCOMES MEASURES: Pharmacists' self-reported frequency of assessment and education; attitudes and beliefs about assessing and educating patients using MDIs; and knowledge of MDI technique. RESULTS: The survey response rate was 53.7% (n = 39) for baseline and 43% (n = 32) for follow-up. Most pharmacists (85.4% at baseline, 87.5% at follow-up; p = 0.79) indicated that they educate patients receiving new MDI prescriptions. In addition, 47.4% at baseline and 68.8% at follow-up indicated they educate patients using inhalers for three months (p = 0.07). Only 21.1% at baseline and 18.8% at follow-up (p = 0.81) indicated that they follow up with long-term users. The mean +/- SD MDI technique knowledge score (steps correct out of 9 possible) at baseline was 7.2 +/- 1.1 and 7.5 +/- 1.3 at follow-up (p = 0.29). Significant changes in level of agreement with some beliefs/attitudes were observed, including the importance of frequently assessing/educating patients, confidence and comfort when assessing/educating patients, and that assessing/educating patients is not the role of only the physician. Respondents continued to acknowledge that MDI education and assessment are important to improving and maintaining control of disease. However, the respondents thought that barriers exist that inhibit this activity, such as not enough time for education and assessment. CONCLUSIONS: Pharmacists reported they frequently educate patients and assess MDI technique for new prescriptions but not very often for patients recently started, as well as for long-term users. Six months after an educational program, attitudes and beliefs toward this activity were either not changed or, in some, improved. Pharmacists perceive that there is not enough time to assess and educate patients who use MDIs.

Adult↗
PubMed1999

Nonprescription and alternative medication use by individuals with HIV disease.

OBJECTIVE: To examine the strength of the associations between predisposing, enabling, and need-for-care variables and the self-treatment of HIV disease; and to compare sociodemographic and illness-related factors associated with the use of vitamins, nonprescription medications, herbs, and recreational substances among HIV-infected individuals. METHODS: Data were derived from 7887 interviews conducted as part of the AIDS Cost and Services Utilization Survey. The conceptual framework was the Andersen Behavioral Model of Health Services Use. Factors associated with nonprescription and alternative medication use were assessed using logistic regression. Generalized estimating equations were applied to adjust variance estimates for within-person correlations of drug use over time. RESULTS: After adjusting for perceived health status, T cell count, and stage of disease, the results indicated that African-Americans were less likely to use nonprescription drugs (odds ratio [OR] 0.65, 95% CI 0.52 to 0.81), vitamins (OR 0.59, 95% CI 0.48 to 0.73), and herbs (OR 0.41, 95% CI 0.22 to 0.76), compared with non-Hispanic whites. Similarly, Hispanics were less likely to report use of herbs (OR 0.58, 95% CI 0.34 to 0.98) or recreational drugs (OR 0.34, 95% CI 0.15 to 0.76) than were non-Hispanic whites. Oppositely, individuals who had a college education were more likely to use vitamins (OR 1.26, 95% CI 1.05 to 1.50) and herbs (OR 2.47, 95% CI 1.56 to 3.91). Enabling variables such as insurance status and income were generally associated only with use of recreational drugs. Need-for-care variables were generally associated only with use of nonprescription drugs and vitamins. CONCLUSIONS: Predisposing, enabling, and need-for-care variables from the Andersen Behavioral Model were significantly associated with the use of four categories of drugs to self-treat HIV disease. However, there was not a consistent pattern across the drug categories.

Adolescent↗
PubMed1999

Research experiences and research-related coursework in the education of doctors of pharmacy.

A study assessed coursework and experiential activities of students to determine the role of research in Doctor of Pharmacy education. Questionnaires were sent to all 78 (at that time) colleges and schools of pharmacy in the United States. Responses were received from 60 (76.9%), of which 57 were used, representing 139 Pharm.D. program types (entry-level, post-B.S., track-in, nontraditional). Most programs required coursework in research methodology, statistics, and drug information and literature evaluation, with research methodology required least. Although 41.0% of programs provided students the opportunity to conduct research as an elective, only 12.9% required an extensive project with data collection, analysis, and write-up. Another 6.5% required a project proposal only. Most colleges of pharmacy now offer the Pharm.D. degree, and the role of the pharmacist has also changed. Pharmacists must be able to disseminate evidence-based knowledge about drug products and drug therapy and use scientific knowledge and scholarly principles to solve problems.

Curriculum↗
PubMed1999

Access and use of medications in HIV disease.

OBJECTIVE: To examine if measures of access to medical care are associated with outpatient use of antiretroviral and Pneumocystis carinii pneumonia (PCP) medications among a cohort of individuals with HIV disease. DATA SOURCES: Adults who participated in a series of up to six interviews as part of the AIDS Costs and Services Utilization Survey (ACSUS). ACSUS, a panel survey of persons with HIV disease, was undertaken from 1991 through 1992. STUDY DESIGN: The Andersen Behavioral Model of Health Services Use provided the conceptual framework for the study. Logistic regression analyses with generalized estimating equations were conducted to determine the effects of predisposing, enabling, and need-for-care factors on the odds of antiretroviral or PCP medication use. The analytic sample consisted of 1,586 respondents whose 7,652 interviews provided the data. PRINCIPAL FINDINGS: The multivariate analysis showed that being female (OR = 0.76; 95% C.I. = 0.60-0.95), ages 15 to 24 years (OR = 0.64; 95% C.I. = 0.44-0.92), and having a hospitalization (OR = 0.73; 95% C.I. = 0.63-0.84) were associated with lower odds of using antiretrovirals. African American race (OR = 1.30; 95% C.I. = 1.04-1.62), having both public and private insurance (OR = 2.11; 95% C.I. = 1.47-3.03), attending counseling (OR = 1.17; 95% C.I. = 1.02-1.34), having a usual source of care (OR = 1.70; 95% C.I. = 1.38-2.11), and clinical trials participation (OR = 1.52; 95% C.I. = 1.23-1.87) were associated with a higher odds of use. Similar results were obtained for analyses of PCP medication use. CONCLUSIONS: Sociodemographic differences exist in access and use of prescription drugs within the ACSUS cohort. The results suggest that women and those ages 15 to 24 years have poor access to some medications that improve survival in HIV disease.

Adolescent↗
PubMed1998

Assessing metered-dose inhaler technique: comparison of observation vs. patient self-report.

The purpose of this study was to develop and determine the validity of a patient-completed questionnaire that assesses metered-dose inhaler (MDI) technique. Self-reported MDI technique was compared to observed technique. The questionnaire included nine steps for MDI use, with two to three response choices for each step. A total of 159 patients were studied. Direct observation revealed that greater than 82% of patients exhibited inadequate technique (more than two out of nine steps incorrect). The mean percentage agreement between the questionnaire and observation was 77.4%. Questionnaire results where in higher agreement with observation when patients performed correct MDI technique.

Adolescent↗
PubMed1997

The determinants of physician attitudes and subjective norms toward drug information sources: modification and test of the theory of reasoned action.

PURPOSE: To improve upon the theory of reasoned action and apply it to pharmaceutical research, we investigated the effects of relevant appraisals attributes, and past behavior of physicians on the use of drug information sources. We also examined the moderating effects of practice characteristics. METHODS: A mail questionnaire asked HMO physicians to evaluate seven common sources of drug information on general appraisals (degree of usefulness and ease of use), specific attributes (availability, quality of information on harmful effects and on drug efficacy), and past behavior when searching for information on a new, simulated H2 antagonist agent. Semantic differential scales were used to measure each appraisal, attribute and past behavior. Information was also collected on practice characteristics. RESULTS: Findings from 108/200 respondents indicated that appraisals and attributes were useful determinants of attitudes and subjective norms toward use. Degree of usefulness and quality of information on harmful effects were important predictors of attitudes toward use for several sources of information. Ease of use and degree of usefulness were important predictors of subjective norms toward use. In many cases, moderating effects of practice characteristics were in opposing directions. Past behavior had significant direct effects on attitudes toward the PDR. CONCLUSIONS: The findings suggest ways to improve the usefulness of the theory of reasoned action as a model of decision-making. We also propose practical guidelines that can be used to improve the types of drug information sources used by physicians.

Attitude of Health Personnel↗
PubMed1996

Design and results of a group counter-detailing DUR educational program.

PURPOSE: The study objectives were to (1) design, (2) implement and (3) evaluate a multi-step educational program as an integral component of a healthcare system's activities to improve medication use quality and control drug costs. Design and implementation of the educational program were based upon established principles of changing prescriber behavior. Two classes of oral medications, antihistamines and antibiotics, were targeted. METHODS: A before-after nonequivalent comparison group design with 2 comparison groups was used for evaluation. Medication claims data from the same time period one year previously were used as historical controls. Prescribing rates, net savings and prescribers' attitudes were assessed. RESULTS: Prescribing trends in the treatment group but not comparison groups generally reflected changes consistent with the educational message. A net savings of $84 was achieved in the antihistamine program. A net loss of ($2722) was seen in the antibiotic program. Over 75 percent of prescribers agreed or strongly agreed that the educational program was an appropriate mechanism to optimize medication use. Level of exposure and practice years affected perceived knowledge gains. CONCLUSION: The group counter-detailing DUR educational program was effective in improving prescribing rates. Prescribing rate changes and economic impacts differed by therapeutic category. The entire program was well accepted among prescribers including physicians and nurse practitioners.

Drug Prescriptions↗
PubMed1996

A reasoned action approach to physicians' utilization of drug information sources.

PURPOSE: The effects of attitude and subjective norm were investigated on physicians' intention to use seven drug information sources: the PDR, medical textbooks, medical journals/newsletters, pharmaceutical manufacturers' literature, pharmaceutical manufacturers' representatives, other physicians, and pharmacists. The effects of past behavior and practice characteristics were also examined. METHODS: An eight-page mail questionnaire queried health maintenance organization physicians on their intention to use, attitude (emotional response) and subjective norm (colleagues' approval/disapproval) toward use of each source when searching for drug information on a fictitious, new H2 antagonist agent. RESULTS: Responses were received from 54% (108) of the 200 physicians surveyed. Positive attitudes toward use had the greatest influence upon intention to use each of the sources (b > or = .40) (except for pharmacists, for which subjective norm was the most important predictor (b = .31)). Past behavior directly affected intention to use the PDR (b = .27), and pharmaceutical manufacturers' literature (b = .26). The effects of attitude and/or subjective norm on intention to use non-commercial sources of drug information were moderated by the practice characteristics. CONCLUSIONS: These findings suggest that physicians' use of drug information sources is strongly influenced by their attitudes toward use. In addition, the importance of situational contingencies should not be overlooked when investigating the use of drug information sources.

Drug Information Services↗
PubMed1995

Intravenous histamine H2-receptor antagonists and parenteral nutrition: patterns of use.

Patterns of use of i.v. histamine h2-receptor antagonists (H2RAs) and parenteral nutrient solutions in patients receiving both given separately or as admixtures were studied. Consecutive adult patients at a university teaching hospital were placed in an "admixed group," consisting of all those who received an i.v. H2RA as a parenteral nutrient solution additive, or a "nonadmixed group," consisting of all those who received an i.v. H2RA and a parenteral nutrient solution as separate infusions. Data were collected for many variables, including interruptions in therapy, route and method of administration, indication for use, total daily dose of H2RA, patient demographic data, and any additional anti-ulcer drugs prescribed. A total of 128 patients received 158 regimens of therapy, 60 regimens in the admixed group and 98 in the nonadmixed group. There was at least one interruption in i.v. H2RA therapy for 32% of the admixed-group regimens and 33% of the nonadmixed-group regimens. When an interruption occurred, patients in the admixed group missed an average of 40% of their daily H2RA dose, compared with 53% for the nonadmixed group. No alternative anti-ulcer drug was given on 10 (23%) of the 42 days when intensive care patients had an interruption in H2RA therapy, versus 33 (55%) of the 60 days of H2RA interruption for non-intensive-care patients. Interruptions in i.v. H2RA therapy occurred more frequently when the H2RA was a component of the nutrient solution than when it was given as a separate infusion. Supplemental anti-ulcer therapy was typically not provided during interruptions in H2RA therapy, regardless of the method of administration.

Adult↗
PubMed1995

Effect of production environment on labor demand in Veterans Affairs medical center pharmacies.

The relationship between pharmacy production environment and labor-time requirements was estimated by using data from Veterans Affairs medical center (VAMC) pharmacies. Economic theory was used to derive equations for estimating labor-time requirements for pharmacy services that take into account differences in production environment (factors that cannot be controlled by the pharmacy manager within a given observation period, such as pharmacy service mix and distance to patient care wards). The equations were estimated by using information obtained from the Department of Veterans Affairs (VA) and from a mail survey of VAMC pharmacy chiefs. The resulting estimates of labor-time requirements were compared with pharmacy labor-time requirements produced by the VA in 1989. Labor-time requirements varied dramatically with production environment, and the labor-time requirements calculated in this study generally exceeded those used by the VA. Accurate forecasts of required pharmacist and technician labor time must take into account the production environment within each pharmacy.

Efficiency, Organizational↗
PubMed1995

Unclaimed prescriptions at a university hospital's ambulatory care pharmacy.

Characteristics of unclaimed prescriptions at a university hospital's ambulatory care pharmacy were determined, and reasons why prescriptions went unclaimed were identified. Over a 15-week period, 522 unclaimed prescriptions for 344 patients were identified. Patient and prescription data for these unclaimed prescriptions were obtained from pharmacy records. Telephone interviews were conducted with 157 patients to determine (1) why they had not claimed their prescriptions and (2) whether their treatment had been interrupted as a result. Of the unclaimed prescriptions, 224 were for discharge medications. Only 38 (17.0%) of the discharge prescriptions were eventually dispensed without pharmacy intervention, compared with 147 (49.3%) of the other unclaimed prescriptions. Patients' reasons for not claiming their prescriptions suggested that they had complied with the physicians' intentions for 72.6% of their prescriptions. The two most frequently reported reasons were that the prescription had been obtained elsewhere and the physician had changed or discontinued the regimen. Unclaimed prescriptions, especially for discharged patients, usually resulted from a lack of communication among patients, pharmacists, and other health care providers.

Adolescent↗
PubMed1995

Comparison of adverse drug reactions detected by pharmacy and medical records departments.

Adverse drug reactions (ADRs) detected by the pharmacy and medical records departments of a multispecialty teaching hospital were studied. The charts of all adult patients who were identified by the pharmacy or medical records departments as having had an ADR and who were discharged from the hospital between July and September 1990 were reviewed. Data on patient demographics and the characteristics of the ADRs were collected, and the causality and severity of each ADR were assessed by two pharmacists and one physician. A total of 110 charts representing 117 ADRs were reviewed. Twenty-five (21%) of the ADRs were identified by the pharmacy department and 101 (86%) by the medical records department; 9 (8%) were reported by both departments. The pharmacy and medical records groups of patients were demographically similar, except that the percentage of patients admitted through the emergency room was significantly smaller for the pharmacy department group. ADRs identified by the pharmacy were most commonly cutaneous, and those identified by medical records were most commonly neurologic. For the pharmacy department, hypersensitivity reactions accounted for the largest number of ADRs, while for medical records the largest number involved abnormal laboratory test values. Anti-infectives were involved in two thirds of the pharmacy-identified ADRs, compared with only a fifth of the ADRs identified by medical records. Mean causality and severity scores did not differ significantly between the groups. The medical records department identified four times as many ADRs as the pharmacy department. Observed differences in the number and types of reactions, manifestations, patient locations, and suspected drugs probably reflect the different surveillance methods and ADR definitions used by the two departments.

Adult↗
PubMed1993

Assessing the quality of pharmaceutical care. I. One perspective of quality.

OBJECTIVE: To evaluate the concept of pharmaceutical care (PC) as a standard of quality care for ambulatory pharmacy practice. DATA SOURCES: Donabedian's article on the seven pillars or characteristics of quality provides a framework for a discussion of the merits of PC as a definition of quality. A MEDLINE search augmented by a manual review of International Pharmacy Abstracts was also used to identify pertinent English-language pharmacy literature; indexing terms included quality, community pharmacy services, ambulatory, pharmacy services, and pharmacist(s). STUDY SELECTION: Representative articles and studies promoting PC were considered. DATA EXTRACTION: The literature was independently reviewed by the primary author. DATA SYNTHESIS: An interpretation of the principles of Donabedian's article was applied to PC. PC appears to be consistent with the quality characteristics of efficacy and acceptability. The effectiveness, cost-effectiveness, and efficiency of PC should be firmly established by its practitioners as barriers are eliminated and/or overcome. The pillars of optimality, equity, and legitimacy seem to be overlooked under the current definition of PC. This article contends that PC assumes an individualist definition of quality, by definition, because of its covenantal relationship with the patient. CONCLUSIONS: Quality is defined in terms of the values of individuals and society. For now, PC appears to be the appropriate standard for defining quality in pharmacy because of the importance of individual maximal benefits within our society.

Cost-Benefit Analysis↗