The purpose of this study was to investigate the impact of Medicare Part D on prescription utilization, health services utilization, and health care expenditures in the general Medicare population – as well as Medicare sub-populations, including non-Hispanic blacks (NHBs), Hispanics, near poor individuals, and persons with higher disease burden. A retrospective analysis of Medicare beneficiaries (N=32,228) was conducted using the Medical Expenditure Panel Survey 2002 to 2009 data. Multivariable quantile regression was used to estimate the following outcomes, adjusting for socio-demographic characteristics: 1) number of prescription fills; 2) out-of-pocket (OOP) drug expenditures; 3) total drug expenditures; 4) OOP health care expenditures; 5) total health care expenditures; 6) number of hospitalizations; and 7) number of emergency department (ED) visits between the pre-Part D (2002-2005) and post-Part D (2006-2009) periods. All expenditures were inflation-adjusted to 2009 dollars. The average age of the study sample was 71.0 (SD=14.5). In the general Medicare population, Part D was associated with decreases in OOP drug expenditures (-25.7% to -33.6%; p<0.0001) and OOP health care expenditures (-22.1% to -24.3%; p<0.0001) as well as increases in the number of prescription fills (5.8% to 8.4%; p<0.0001) and total drug expenditures (75th percentile: 5.5%; 90th percentile: 10.2%; p<0.0001). Part D was not associated with changes in total health care expenditures in the general Medicare population. Changes in hospitalizations and ED visits were tested at the 90th percentile, and the results were not statistically significant. In sub-group analyses based on race/ethnicity, non-Hispanic whites (NHWs) experienced more significant reductions in OOP drug and/or health care expenditures when compared with NHBs and Hispanics. Near poor beneficiaries experienced larger reductions in OOP drug expenditures than beneficiaries with middle- to high-income, while Medicare beneficiaries with three or more conditions experienced more substantial reductions in OOP drug and OOP health expenditures after Part D was introduced, compared with those with fewer than three conditions. Part D resulted in increases in medication utilization and reductions in OOP drug and OOP health care expenditures among Medicare beneficiaries. Part D was not associated with differences in total health care spending. The effects of Part D were more pronounced in Medicare subgroups, including NHWs, near poor individuals, and patients with higher chronic disease burden. / text

This study intended to examine the effects of Direct-to-Consumer prescription drug advertising (DTCA). Looking specifically for the behavioral effects that exposure to DTCA had on consumers, data was collected about respondents’ actions after seeing or hearing an advertisement for a prescription drug. Application of the Theory of Planned Behavior and the Theory of Uses and Gratifications demonstrated the potential psychological factors at play throughout consumers’ decision making process. Advertising congruence with media use was an important aspect of the study as well as grasping respondents’ perception of behavioral control with regard to requesting prescription drugs from their doctor. A small portion of this study examined how physician prescribing behavior was affected by DTCA. / text

National health expenditures will continue to grow faster than nominal gross domestic product (GDP) in the early 21st century (Heffler et al., 2002; Heffler et al., 2005). Increased Medicaid costs have spurred research to find reliable cost-saving methodologies (Kronick et al., 1996). The Medicaid administrations of some states have chosen risk adjustment as a methodology for savings (Tollen et al., 1998; Weiner et al., 1998), since it can reduce the financial burden of health care providers and distribute medical resources more efficiently. This dissertation presents a risk-adjustment model based on two types of health condition adjusters: diagnosis-based HCC adjusters and pharmacy-based RxRisk adjusters. HCC adjusters were developed from different diagnostic categories from inpatient, outpatient and long-term care data. RxRisk adjusters included diseases inferable from prescription drug usage. The underlying assumption is that using both types of health condition adjusters, rather than relying on either diagnosis-based adjusters or pharmacy-based adjusters alone can help increase predictive power and lower Medicaid's risk of reimbursing inflated medical costs for its beneficiaries. The population in this study consisted of all disabled and aged Florida adults who were eligible for Florida's Medicaid program in state fiscal year (SFY) 2002-03 and state fiscal year 2003-04. The population was broken down into two subpopulations: disabled Medicaid beneficiaries aged 64 and under and beneficiaries aged 65 or over.The proposed regression model includes diagnostic and pharmacy-based adjusters, and this dissertation compares the proposed model with models based solely on pharmacy- or diagnosis-based adjusters.The results presented in this dissertation demonstrate the proposed model has higher predictive power than the diagnosis-based HCC model and the pharmacy-based RxRisk model for the overall population and the subpopulations in this study. Risk-adjustment models using diagnostic and prescription drug information have higher predictive power and decrease the possibility of inappropriate gaming of the Medicaid capitation payment system.

Trust in direct-to-consumer (DTC) pharmaceutical advertising is declining among consumers. Survey findings suggest providing more information about side effects and benefits to address this issue. Some scholars also criticize the ads for their emotional content despite the key role emotion can play in health-related decision making and trust. Therefore, an experimental study was conducted to assess the relative effectiveness of functional and emotional benefit communication as well the preferred balance of side effects and benefits information provided in DTC pharmaceutical ads in terms of perceived credibility/trust and persuasive outcomes. Results suggest a message including a combination of functional and emotional benefits is considered more credible and informative than an ad describing only emotional benefits. In addition, a high amount of side effect information produces lower brand attitudes and greater perceptions of manipulative intent compared to a low amount of side effect information. Implications for pharmaceutical advertising practitioners and researchers are discussed. / text

Misuse of prescription anxiolytic and sedative medication is a widespread phenomenon in Canada and a topic of increasing concern among health care providers. While anxiolytics and sedatives have important therapeutic uses in the treatment of anxiety and insomnia, these substances have psychoactive properties that render them vulnerable to misuse. Understanding the correlates and contexts of misuse is essential for developing targeted treatment and prevention strategies. This dissertation is comprised of a series of four studies conducted with adults in the Halifax Regional Municipality, recruited from the community and from a local substance use disorder treatment program. Study 1 investigated misuse of anxiolytics and sedatives among currently prescribed users of these medications in the general community. Misuse and diversion were associated with a more extensive history of other substance use and with personality dimensions, including hopelessness and impulsivity. Study 2 investigated motives for misuse among non-prescribed anxiolytic and sedative users recruited from the community. This study also included non-prescribed stimulant medication users to facilitate comparisons across differing classes of psychiatric medications. Non-therapeutic motives were associated with substance use history and, for anxiolytics and sedatives, with the personality dimension sensation-seeking. Study 3 involved an analysis of prescription regimens and misuse among all participants of Studies 1 and 2 who had ever held a prescription for an anxiolytic or sedative. Misuse of benzodiazepine anxiolytics and sedatives was more frequent than that of non-benzodiazepines, but was unrelated to prescription regimen. Study 4 examined the misuse of quetiapine, an atypical antipsychotic medication with anxiolytic and sedative effects, among clients of a methadone maintenance program. Misuse of quetiapine was widespread, but was typically associated with therapeutic motives. Quetiapine misuse was linked with a history of misusing other anxiolytic and sedative drugs. Collectively, these studies provide evidence that anxiolytic and sedative misuse is a heterogeneous phenomenon encompassing varying patterns of use and motives for misuse. Furthermore, these investigations suggest that anxiolytic and sedative misuse is linked to individual-level and medication-related variables. By providing a more comprehensive characterization of this important public health issue, these findings have practical implications in both clinical and research contexts.

This study determined whether a cadenced-based exercise prescription (CBEP) enabled participants to increase the time they spend doing moderate-to-vigorous intensity physical activity (MVPA) to a greater extent than Standard Care (SC). Forty-six participants were recruited from the ENCOURAGE study and were allocated to SC (n=25) or CBEP (n=21). Data was collected at baseline (T0), prior to the intervention (T1) and then again at 16 (T2) and 24 (T3) weeks. Moderate-to-vigorous physical activity was assessed by accelerometry in 10 minute (MVPA10min) and sporadic bouts (MVPASpor) as well as step counts (StepsTotal, StepsMVPA). Although participants reported that CBEP helped them to increase their motivation to become more active, none of the accelerometer parameters differed between SC and CBEP at baseline, 8, 16, or 24 weeks. These data suggest that CBEP did not have an added benefit for influencing physical activity over time amongst a population of previously sedentary adults.

This study determined whether a cadenced-based exercise prescription (CBEP) enabled participants to increase the time they spend doing moderate-to-vigorous intensity physical activity (MVPA) to a greater extent than Standard Care (SC). Forty-six participants were recruited from the ENCOURAGE study and were allocated to SC (n=25) or CBEP (n=21). Data was collected at baseline (T0), prior to the intervention (T1) and then again at 16 (T2) and 24 (T3) weeks. Moderate-to-vigorous physical activity was assessed by accelerometry in 10 minute (MVPA10min) and sporadic bouts (MVPASpor) as well as step counts (StepsTotal, StepsMVPA). Although participants reported that CBEP helped them to increase their motivation to become more active, none of the accelerometer parameters differed between SC and CBEP at baseline, 8, 16, or 24 weeks. These data suggest that CBEP did not have an added benefit for influencing physical activity over time amongst a population of previously sedentary adults.

Cord blood IgE has previously been studied as a possible predictor of asthma and allergic diseases. Results from different studies have been contradictory, and most have focused on high-risk infants and early infancy. Few studies have followed their study population into adulthood. This study assessed whether cord blood IgE levels and a family history of asthma were associated with, and could predict, asthma medication and allergy-related respiratory symptoms in adults. A follow-up was carried out in a Swedish birth cohort comprising 1701 consecutively born children. In all, 1661 individuals could be linked to the Swedish Prescribed Drug Register and the Medical Birth Register, and 1227 responded to a postal questionnaire. Cord blood IgE and family history of asthma were correlated with reported respiratory symptoms and dispensed asthma medication at 32–34 years. Elevated cord blood IgE was associated with a two- to threefold increased risk of pollen-induced respiratory symptoms and dispensed anti-inflammatory asthma medication. Similarly, a family history of asthma was associated with an increased risk of pollen-induced respiratory symptoms and anti-inflammatory medication. However, only 8% of the individuals with elevated cord blood IgE or a family history of asthma in infancy could be linked to current dispensation of anti-inflammatory asthma medication at follow-up. Elevated cord blood IgE and a positive family history of asthma were associated with reported respiratory symptoms and dispensed asthma medication in adulthood, but their predictive power was poor in this long-time follow-up. / <p>The status of this article was on the day of the defence date <em>Manuscript</em>.</p>

Direct-to-consumer (DTC) advertising of prescription products is the promotion of prescription-only medicine (POM) to the general public through commercial media. It is a new promotional tool for prescription drugs. Traditionally, pharmaceutical companies have promoted their products to licensed health care professionals only; any direct communication with consumers has been avoided. In the USA and New Zealand, however, DTC advertising is officially allowed. / In Hong Kong, DTC advertisement has never been specially prohibited, but it is not openly endorsed either. Printed advertisements of prescription only medicines started to appear in newspapers in Hong Kong after the relaxation of regulations in 1997. More and more advertisements of prescription-only drugs are appearing in local newspapers and magazines. However, the doctor is the one who makes the diagnosis of the disease and decides the appropiate prescriptions and advertising to consumers may not necessarily affect the prescribing habits of the doctors. It could be useful therefore for the development of local marketing strategies to determine the views and attitudes of physicans and consumers in Hong Kong towards DTC advertising of prescription pharmaceutical products. / Thesis (DBA(DoctorateofBusinessAdministration))--University of South Australia, 2007.

Prescription medicine samples are a product based promotion designed to facilitate brand switching or uptake of a new product. Marketing of pharmaceuticals differs from other products since the primary decision maker (doctor) is not the ultimate consumer (patient). Marketing of medicines also has an overlay of government regulations and political influence. It is argued whether free samples of prescription medicines provided to doctors constitute a “gift” or a trial quantity with which to initiate therapy and test patient tolerance of the drug concerned. Either way, samples are an integral part of the prescription medicine marketing tapestry and they have become woven into the “fabric” of drug promotion. The international literature abounds with papers describing pharmaceutical promotion and myriads of surveys obtaining prescribers’ opinions about pharmaceutical promotion. Few studies have been conducted or reported to ascertain the reasons behind the opinions expressed as disagreement/agreement scales to specific statements. Interventions to alter practice targeting alternative methods of distribution of samples (rather than direct from company to prescriber) are also rare; therefore the aim of this research was to qualitatively explore opinions regarding samples to develop an intervention to ensure samples do not have an adverse effect on prescribing practice and to test the model in a practice environment. In order to assess the place of samples within the totality of pharmaceutical promotion, a model was derived from the literature and tested with a hypothetical, but realistic practice-based scenario. This highlighted the interplay between the various methods involved in pharmaceutical promotion, their target audiences and the potential interplay and synergism that could be achieved through a co-ordinated campaign. Quantification of the expenditure on samples was also required in the Australian context to assess the potential impact of interventions targeting this promotional mode. Samples were found to account for approximately 5% of the total marketing spend in Australia. No clear relationship could be found between sample expenditure and drug sales, utilizing data on the proton pump inhibitor therapeutic class. However, a pattern of decaying spending was found between the amount spent on samples per unit pack dispensed and the time a product had been available on the market. A range of interested parties were then interviewed to gain their opinions about free prescription medicine samples. The interviews were split into two groups: consumers, pharmacists and practicing general practitioners (GPs) provided an operational level focus, while a range of key informants from organisations involved in Quality Use of Medicines in Australia provided a strategic overview. The transcripts of the focus groups and interviews were qualitatively analysed to extract key themes which were quite similar. Examples included ‘pay’ in the operational group compared to ‘cost’ in the strategic group. These concepts express a similar sentiment, yet ‘pay’ is a more personal action whereas ‘cost’ does not imply who must meet the financial outlay. These resultant themes formed the basis of the intervention developed to pilot in a practice environment to assess its practicality for wider study. In addition to the extensive interview process, a mail survey was conducted in three divisions (geographical groupings) of general practice. Each family doctor (General Practitioner (GP)) and community pharmacist within the divisions received a questionnaire to gather their opinions about samples. This was the first time GPs and pharmacists had been surveyed simultaneously to gather comparative results. No differences were found between the metropolitan division and the accumulated results from the two regional divisions. Pharmacists and GPs differed predominantly in their perceptions of promotional influence of samples, appropriateness of self use and meeting legal requirements for labelling dispensed medicines. These factors were incorporated in the pilot study design. An action research methodology was utilised to assess the practicality of community pharmacist dispensing of starter packs for antihypertensives and antidepressants in two regional GP practices in Queensland, Australia. In this pilot study, a total of 32 starter packs were prescribed to 31 patients over the four months of the intervention period, with 29 (91%) dispensed at a study pharmacy and 17 (53%) of subsequent full prescriptions able to be tracked through Medicare Australia data or the study pharmacies. Antidepressants comprised the majority of prescriptions (n=16, 55%) Each of the 29 patients who received a starter pack completed a patient survey which demonstrated high levels of support (n=22, 76%) for the model in the pilot. GPs and pharmacists involved in the pilot were also generally supportive of the pilot model. In conclusion, opinions held about free prescription medicine samples by a wide range of apparently disparate groups show similar themes and community pharmacist involvement in dispensing starter (or sample) packs has general acceptance. The model piloted in this research was applicable in daily practice for general practitioners and community pharmacists in Australia. Consumers accepted the pilot model as an acceptable change to current procedures. The research presented in this thesis provides a solid foundation for development of a more widespread trial for dispensing of all prescription medicine starter packs through community pharmacies to be rigorously evaluated in Australia.