Class of 2007 Abstract / Objectives: The purpose of this study is to determine if an antibiotic formulary is beneficial in an inpatient ICU setting. The main goal, of course, is to ensure patients receive the most appropriate antimicrobial therapy resulting in the least amount of resistance, by using an antibiotic formulary and ICU antibiotic intervention. Methods: This project will use a retrospective design in which one-year post-intervention antibiotic resistant trends will be compared with pre-intervention trends at Yuma Regional Medical Center (YRMC). As is common at YRMC, patients started on antibiotic therapy had susceptibility testing performed to determine the best treatment for the patient. This susceptibility data will be the data used for comparison. Comparison of patient charges and hospital costs associated with these patients will also be performed. YRMC employed an ICU antibiotic intervention documentation form that was used to monitor and extrapolate intervention data. Hospital lab percent susceptibility data will be looked at to determine isolate susceptibility data to determine if any trends are present in antibiotic resistance between the time period when the antibiotic formulary was implemented and the previous corresponding period of time before the formulary. This data will also be compared with the hospital trends in resistant isolates as a whole. The data is desensitized, as individual patient data is not being reviewed. In looking at patient charges and hospital costs, charts will be reviewed. These charts will be de-identified to the investigators of this study. Of further note, YRMC placed the intervention in action in February 2006 and began collecting post-intervention data at that time. This study will be using post intervention data collected from February 2006 thru February 2007. Results: Conclusions:

No description available.

The European Commission is currently working on a legislative draft to harmonise the corporate income tax provisions for multinational groups of companies throughout the European Union. For that purpose the European Commission has installed a working group with the mission to draft a Common Consolidated Corporate Tax Base (CCCTB) applicable for multinational companies. As the EU member states are not willing to surrender their taxing power to the supranational level of the EU each group entity's tax base would be determined by apportionment of the group's overall taxable income according to a predefined micro-economic factor based formula whereas the group income will be calculated by consolidating earnings beforehand separately determined by each group entity (preconsolidation income). The situs state of the particular group entity would then apply its statutory corporate tax rate on the apportioned tax base. This paper evaluates the effects of this prospective apportionment procedure on any given corporate group entity and finds that the share of the group's income allocated to a particular entity using the apportionment formula does regularly not equal the pre-consolidation income of the respective group entity. The reasons for this regular observable deviation can be found on the one hand in the concept of the apportionment formula and on the other hand in the specifics of the definitions of the apportionment factors. (author's abstract) / Series: Discussion Papers SFB International Tax Coordination

Background: Hospital drug formularies are developed in order to support safe, effective and cost-effective prescribing. Their utilisation is based on the assumption that prescribers and other users will follow guidance outlined within them. The role of formulary users’ attitudes has been largely overlooked in the research literature. The nature and impact of attitudes to formularies on influencing prescribing practice have not been fully investigated. This study seeks to address this issue through a local practice based research project. Objectives: To determine the attitudes and experiences of users and key stakeholders with the utilisation of a new formulary at a local hospital trust. Methodology: Semi-structured interviews were conducted exploring the views of doctors, pharmacists and non-medical prescribers. An online self-completion questionnaire was sent to all key stakeholders. In addition prescribing data was also extracted from the Pharmacy computer system to assess impact of the new formulary. Data collection was thus split into two phases with modifications made to the formulary based on preliminary findings and emerging themes. Results: The local formulary symbolises a ‘critical split’ in the approach to resource management and patient care. Pharmacists are ‘closely bound’ to the formulary, relying on it for retrospective decision-support and ultimately seen to improve pharmacists’ autonomy while prescribers consider it to be over-rationalisation eroding their professional autonomy. Although the quantitative data in this study demonstrates a statistically significant improvement in doctors’ perceptions of using the formulary, the distinct divide between doctors’ and pharmacists’ attitudes towards the formulary remained. Prescribing data extracted showed no significant impact of the formulary on prescribing practice. Conclusion: The study confirms the existence of deeper sociological constructs, particularly concerning autonomy and professionalism. Doctors claim an ability to manage uncertainty during patient consultations while pharmacists claim to be drug ‘experts’. The monopoly on drug knowledge is therefore contested ground. This study concludes that both the formulary and the pharmacy profession need to be more influential, and embrace a more ‘humanised-bureaucracy.’ It is recommended that pharmacists build on a new philosophical union with the formulary and focus on asserting their claim and dominance on the monopoly of drug knowledge.

Pharmacy and Therapeutics (P&T) Committees manage programs that provide patients with effective, safe, and financially sound medication treatments. Despite their importance, little research exists into what committee characteristics lead to adoption of its decisions by prescribers. Considered as "teams", research from the management literature and a qualitative study identified a theoretical model of P&T Committee performance that includes five concepts and a set of four outcome measures. The study aims were to: (1) Describe the variance in P&T Committee functioning and performance in the United States, (2) Quantify drivers of performance within the P&T Committee Performance model and (3) Quantify the relationships between concepts in the P&T Committee model and the effects of these relationships on P&T Committee performance. An on-line and mail cross-sectional survey was sent to 321 Pharmacy Directors, Hospital Administrators/Medical Staff Directors and P&T Committee Chairs at non-university non-specialty hospitals with an ASHP residency. Previously validated measures were used for two concepts, and newly created measures for three concepts. Four dependent variables were used: adoption of formulary medications, medication restrictions, Community-Acquired Pneumonia (CAP) treatment and Deep Vein Thrombosis (DVT) risk assessment protocols. Multivariate regression and path analysis were used with the dependent variables, with five primary variables of interest and five control variables. The response rate was 17.76%. P&T Committee developed processes are successful in leading prescribers to adopting formulary medication decisions (96.02 ± 3.94%), with no differences based on hospital characteristics. They have not been as successful in developing processes for adoption of decisions on medication restrictions (77.02 ± 28.81%) and protocols (63.02 ± 32.76%, 73.02 ± 29.96%). Engaged team members were important in the adoption of all four studied P&T Committee decisions. Influential physicians and implementation activities varied in their importance depending on the decision being made. The presence of influential physicians on the P&T Committee appeared to facilitate both implementation activities and engagement of team members. Influences outside of the committee were insignificant as predictors of decision adoption, possibly an indicator of successful efforts mitigating their influence. This research begins to address previous research gaps about factors affecting adoption of P&T Committee decisions.

Please read the abstract in the dissertation / Dissertation (MEd)--University of Pretoria, 1974. / Curriculum Studies / Unrestricted

Short-Term Medical Missions (STMMs) seek to provide healthcare services to people where poverty remains prevalent and limited healthcare access remains prevalent. While STMMs increase access to quality healthcare, contributions may not yet be optimal. Traveling medical professionals make a diagnosis and treatment plan based on previously established knowledge. While these treatment plans may prove to be acceptable, plans may not fully consider local customs, or ongoing medication access. A comprehensive literature review was conducted to determine best practices in developing a formulary for STMMs to investigate if an evidence-based Diagnosis & Treatment Formulary (D&TF) improves cost and time efficiency. The World Health Organization (WHO) executive summary, global essential medicines list, and the International Pharmaceutical Federation and WHO joint guidelines on good pharmacy practice were reviewed for best practices and formulary guidance. The National Institutes of Health’s PubMed, Cumulative Index to Nursing and Allied Health Literature, and the Web of Science Core Collection were searched using keywords cost-effective, evidence-based, formulary, missions, and pharmacy. Fourteen articles were identified and reviewed with inclusion criteria including English language and both within the U.S. and outside the U.S. Exclusion criteria included reviews, editorials, letter publications, and publications prior to 2005. Current best practices for STMM formularies include utilizing the WHO’s sample formulary and guiding principles to develop a team formulary. Formularies for STMMs should be specific to the WHO region, address primary health needs while including medications based on disease prevalence, utilize locally available and affordable medications, and incorporate easy-to-read pictorial medication dispensing labels in the region’s native language. Through literature review, considerations for development and implementation of WHO regional D&TFs have been identified. Appropriate diagnoses and provision of optimal medication regimens relevant to a region’s primary health needs are critical in delivering healthcare services during STMMs. Improving provider confidence in prescribing, increasing team efficiency in medication provision, and advancing equitable health care that is patient-centered and safe, are possible benefits of improved formulary practices. D&TFs go beyond a list of medications by providing an evidence-based treatment regimen for each diagnosis. A need for D&TFs for STMMs that can be further individualized has been identified. The recommended prescription for developing a D&TF for STMMs is for it to include evidence-based treatment plans, utilize essential medicines, be cost-effective, and locally relevant. Pictorial labels should be developed, utilizing local language on any text. STMM teams will need education on the prescription utilized to develop the formulary and its expected benefits to assist with implementation.

The thesis examines the international taxation rules of the Common Consolidated Corporate Tax Base (CCCTB) and their interaction with third-country corporate tax practice. The aim is to assess the effectiveness of the CCCTB vis-à-vis third countries, with Egypt as a practical example. The CCCTB has the potential to reduce corporate tax obstacles faced by businesses in the EU in having to comply with up to twenty seven different domestic systems for determining their taxable profits. However, the international taxation rules of the CCCTB system are likely to have an impact on the corporate tax practice in third countries, and may conflict with existing bilateral tax treaties concluded between CCCTB-Member States and third countries. The discussion presents a detailed analysis of the CCCTB’s unilateral framework for the avoidance of double taxation and for the protection of the common consolidated tax base. It reveals that, by means of ordinary credit and exemption methods provided in the CCCTB Directive, international double taxation will be eliminated in relation to third countries. Furthermore, the CCCTB’s anti-abuse rules are effective in protecting the common tax base and in eliminating non-double taxation. Nevertheless, the unilateral measures are in conflict with a number of important provisions of bilateral tax treaties, based on the OECD Model, concluded between the potential CCCTB-Member States and third countries. Egypt exemplifies this – but the problem is generic. These conflicts between the CCCTB and OECD Model bilateral treaties are detrimental to the effective functioning of the CCCTB system vis-à-vis third countries, and need to be redressed. This thesis suggests a simple and practical solution - replacement of the bilateral tax treaties between CCCTB-Member States and third countries with a multilateral tax treaty to be concluded between every third country and all CCCTB-Member States.

Em estudo realizado com 167 pacientes ambulatoriais idosos atendidos em serviço especializado de geriatria em centro de saúde escola, localizado no bairro da Consolação, no município de São Paulo (SP), foi avaliado o perfil farmacoepidemiológico, investigado se as listas de medicamentos padronizados coincidem com as prescrições e estimados os custos da medicação utilizada. Para este estudo, foram utilizadas informações extraídas dos prontuários médicos e obtidas através de entrevistas com os pacientes ou seus acompanhantes responsáveis. A maioria foi do sexo feminino (74,4%), a média de idade foi 80,4 anos, sendo 71 pacientes entre 60 e 79 anos e 96 entre 80 e 96 anos. Os participantes apresentaram condições socioeconômicas acima da média da população brasileira na faixa etária estudada. O perfil de morbidade, entre os pacientes entrevistados, mostrou média de 6,3 (± 2,5) diagnósticos. O número de medicamentos prescritos a cada paciente foi em média 6,1 (± 2,7). Não houve correlação significativa entre as variáveis pessoais pesquisadas e o número de doenças ou medicamentos registrados. No total foram 1.018 medicamentos prescritos, a maioria (82,9%) de padronizados e distribuídos gratuitamente pelo serviço público. A estimativa de gasto mensal pelo governo com a aquisição desses medicamentos foi de R$ 4.100,55, R$ 24,55/paciente/mês, equivalentes a US$ 11,92/paciente/mês (US$ 0,40/dia). Para 100 pacientes foi registrado pelo menos um medicamento não padronizado, observando-se alguns fármacos indisponíveis na padronização com prevalência relativamente alta de prescrição (memantina, mirtazapina, zolpidem, domperidona). É sugerido um estudo para revisão da padronização de medicamentos para o tratamento de pacientes idosos. / In study carried out with 167 elderly outpatients attended in specialized geriatric service in Centro de Saúde Escola, located in Consolação district, in the municipality of São Paulo, was evaluated the pharmacoepidemiological profile, investigating if the standardized medicament lists match with the prescriptions and estimated the costs from the utilized medication. For this study it was used information extracted from the medical handbooks and obtained through interviews with the patients or their accompanying charge. The majority was female (74,4%), average age of 80,4 years old, being 71 patients between 60 and 79 years old, and 96 between 80 and 96 years old. The participants presented socio-economic conditions above the Brazilian average in the age group studied. The morbidity profile, between the interviewed patients, shown an average of 6,3 (± 2,5) diagnostics. The number of medicaments prescribed to each patient had an average of 6,1 (± 2,7). There were no significantly correlation between the personal variables researched and the number of diseases or medicaments registered. In total 1.018 medicaments were prescribed, the majority (82,9 %) of standardized and freely distributed by the public service. The estimative of monthly cost by the government with the acquisition of these medicaments was R$ 4.100,55, R$ 24,55 by patient a month, equivalent to US$ 11,92 a month (US$ 0,40 a day). For 100 patients was registered at least one non standardized medicament, observing some unavailable drugs on the standardization with relatively high prescription prevalence (memantine, mirtazapine, zolpidem, domperidone). It\'s suggested a revision study from the standardization of medicaments for treatment of elderly patients.

The Formulary Approach to the Taxation of Transnational Corporations: A Realistic Alternative? Synopsis The central hypotheses of this thesis are: that global formulary apportionment is the most appropriate method for the taxation of transnational corporations (TNCs) in lieu of the present system commonly referred to as the separate accounting/arm's length method; and that it is essential, in order to implement the proposed global formulary model, to create an international organisation which would fulfil, in the taxation field, a role equivalent to that of the World Trade Organisation (WTO) in international trade. The world economy is fast integrating and is increasingly dominated by the activities of transnational enterprises. These activities create a dual tax problem for various revenue authorities seeking to tax gains derived thereon: Firstly, when two or more countries entertain conflicting tax claims on the same base, there arises what is commonly referred to as a double taxation problem. Secondly, an allocation problem arises when different jurisdictions seek to determine the quantum of the gains to be allocated to each jurisdiction for taxation purposes. The traditional regime for solving both the double taxation and the allocation problem is enshrined in a series of bilateral treaties signed between various nations. These are, in general, based on the Organisation for Economic Co-operation and Development (OECD) Model Treaty.1 It is submitted, in this thesis, that while highly successful in an environment characterised by the coexistence of various national taxation systems, the traditional regime lacks the essential attributes suitable to the emerging 'borderless world'. The central theme of this thesis is the allocation problem. The OECD Model attempts to deal with this issue on a bilateral basis. Currently, the allocation problem is resolved through the application of Articles 7 and 9 of the OECD Model. In both instances the solution is based on the 'separate enterprise' standard, also known as the separate entity theory. This separate accounts/arm's length system was articulated in the 1930s when international trade consisted of flows of raw materials and other natural products as well as flows of finished manufactured goods. Such trade is highly visible and may be adequately valued both at the port of departure or at the port of entry in a country. It follows that within this particular system of international trade the application of the arm's length principle was relatively easy and proved to be extremely important in resolving both the double taxation and apportionment problems. Today, however, the conditions under which international trade is conducted are substantially different from those that prevailed until the 1960s. * Firstly, apart from the significant increase in the volume of traditionally traded goods, trade in services now forms the bulk of international exchanges. In addition, the advent of the information age has dramatically increased the importance of specialised information whose value is notoriously difficult to ascertain for taxation purposes. * Secondly, the globalisation phenomenon which gathered momentum over the last two decades has enabled existing TNCs to extend their global operations and has favoured the emergence of new transnational firms. Thus, intra-firm trade conducted outside market conditions accounts for a substantial part of international trade. * Thirdly, further economic integration has been achieved following the end of the Cold War and the acceleration of the globalisation phenomenon. In this new world economic order only TNCs have the necessary resources to take advantage of emerging opportunities. The very essence of a TNC is 'its ability to achieve higher revenues (or lower costs) from its different subsidiaries as a whole compared to the results that would be achieved under separate management on an arm's length basis.'2 Yet, the prevailing system for the taxation of TNCs overlooks this critical characteristic and is therefore incapable of fully capturing, for taxation purposes, the aggregate gains of TNCs. The potential revenue loss arising from the inability of the present system to account for and to allocate synergy gains is substantial. It follows that the perennial questions of international taxation can no longer be addressed within the constraints of the separate entity theory and a narrow definition of national sovereignty. Indeed, in order to mirror the developments occurring in the economic field, taxation needs to move from a national to an international level. Moreover, a profound reform of the system is imperative in order to avoid harmful tax competition between nations and enhance compliance from TNCs. Such a new international tax system needs to satisfy the test of simplicity, equity, efficiency, and administrative ease. To achieve these objectives international cooperation is essential. The hallmark of international cooperation has been the emergence, after World War II, of a range of international organisations designed to facilitate the achievement of certain goals deemed essential by various nations. The need for an organisation to deal specifically with taxation matters is now overwhelming. Consequently, this thesis recommends the creation of an international organisation to administer the proposed system. The main objective of this international organisation would be to initiate and coordinate the multilateral application of a formulary apportionment system which, it is suggested, would deal in a more realistic way with 'the difficult problems of determining the tax base and allocating it appropriately between jurisdictions'.3 The global formulary apportionment methodology is derived from the unitary entity theory. The unitary theory considers a TNC as a single business which, for convenience, is divided into 'purely formal, separately-incorporated subsidiaries'.4 Under the unitary theory the global income of TNCs needs to be computed, then such income is apportioned between the various component parts of the enterprise by way of a formula which reflects the economic contribution of each part to the derivation of profits. The question that arises is whether the world of international taxation is ready for such a paradigm shift. It is arguable that this shift has already occurred albeit cautiously and in very subtle ways. Thus, the latest of the OECD Guidelines on the transfer pricing question provides that 'MNE [Multinational Enterprise] groups retain the freedom to apply methods not described in this Report to establish prices provided those prices satisfy the arm's length principle in accordance with these Guidelines.'5 Arguably, the globalisation process has created 'the specific situation' allowed for by the OECD. This thesis, therefore, explores the relative obsolescence of the bilateral approach to the taxation of TNCs and then suggests that a multilateral system is better adapted to the emerging globalised economy. The fundamental building blocks of the model proposed in this thesis are the following: * First, the administration and coordination of the proposed system is to be achieved by the creation of a specialised tax organisation, called Intertax, to which member countries would devolve a limited part of their fiscal sovereignty. * Second, in order to enable the centralised calculation of TNC's profits, the proposed system requires the formulation of harmonised methods for the measurement of the global profits of TNCs. Therefore, the efforts of the International Accounting Standards Committee (IASC) to produce international accounting standards and harmonised consolidation rules must be recognised and, if needs be, refined and ultimately implemented. * Third, the major function of Intertax would be to determine the commercial profits of TNCs on a standardised basis and to apportion the latter to relevant countries by way of an appropriate formula/formulas. Once this is achieved, each country would be free, starting from its share of commercial profits, to determine the taxable income in accordance with the particular tax base that it adopts and, ultimately, the tax payable within its jurisdiction. In the proposed system, therefore, a particular country would be able to independently set whatever depreciation schedules or investment tax credits it chooses, and adopt whatever tax accounting rules it deems fit relative to its policy objectives. Moreover, this thesis argues that the global formulary apportionment model it proposes is not dramatically opposed to the arm's length principle. Indeed, it suggests that the constant assumption to the contrary, even with regard to the usual formulary apportionment methodology, is extravagant because both methodologies are based on a common endeavour, that is, to give a substantially correct reflex of a TNC's true profits. It has often been objected that global formulary apportionment is arbitrary and ignores market conditions. This thesis addresses such concerns by rejecting the application of a single all-purpose formula. Rather, it recognises that TNCs operating in different industries require different treatment and, therefore, suggests the adoption of different formulas to satisfy specific industry requirements. For example, the formula applicable to a financial institution would be different to that applicable to the pharmaceutical industry. Each formula needs to be based on the fundamental necessity to capture the functions, taking into consideration assets used, and risks assumed within that industry. In addition, if the need arises, each formula should be able to be fine-tuned to fit specific situations. Moreover, it is also pertinent to note that the OECD already accepts 'the selected application of a formula developed by both tax administrations in cooperation with a specific taxpayer or MNE group...such as it might be used in a mutual agreement procedure, advance transfer pricing agreement, or other bilateral or multilateral determination.'6 The system proposed in this thesis can thus be easily reconciled with the separate accounting/arm's length which the OECD so vehemently advocates. Both models have the same preoccupations so that what is herein proposed may simply be characterised as an institutionalised version of the system advocated by the OECD. Multilateral formulary apportionment addresses both the double taxation and the allocation problems in international taxation. It resolves the apportionment question 'without depending on an extraordinary degree of goodwill or compliance from taxpayers.'7 It is therefore submitted that, if applied on a multilateral basis with a minimum of central coordination, it also seriously addresses the double taxation problem. Indeed, it is a flexible method given that different formulas may be devised to suit the needs of TNCs operating in different sectors. Consequently, formulary apportionment understood in this sense, is a realistic alternative to the limitations of the present system.