Exploring the use of pharmaceutical patient assistance programs as an option to improve access to and affordability of prescription drugs

Background. Pharmaceutical-sponsored patient assistance programs (PAPs) are charity programs that provide free or reduced-priced medications to eligible patients. PAPs have the potential to improve prescription drug accessibility for patients but currently there is limited information about their use and effectiveness. ^ Objectives and methods. This dissertation described the use of PAPs in the U.S. through the conduct of two studies: (1) a systematic review of primary studies of PAPs from commercially-published and “grey” literature sources; and (2) a retrospective, cross-sectional study of cancer patients' use of PAPs at a tertiary care cancer outpatient center. ^ Results. (1) The systematic review identified 33 studies: 15 evaluated the impact of PAP enrollment assistance programs on patient healthcare outcomes; 7 assessed institutional costs of providing enrollment assistance; 7 surveyed stakeholders; 4 examined other aspects. Standardized mean differences calculated for disease indicator outcomes (most of which were single group, pre-posttest designs) showed significant decreases in glycemic and lipid control, and inconsistent results for blood pressure. Grey literature abstracts reported insufficient statistics for calculations. Study heterogeneity made weighted summary estimates inappropriate. Economic analyses indicated positive financial benefits to institutions providing enrollment assistance (cost) compared to the wholesale value of the medications provided (benefit); analyses did not value health outcomes. Mean quality of reporting scores were higher for observational studies in commercially-published articles versus full text, grey literature reports. (2) The cross-sectional study found that PAP outpatients were significantly more likely to be uninsured, indigent, and < 65 years old than non-PAP patients. Nearly all non-PAP and PAP prescriptions were for non-cancer conditions, either for co-morbidities (e.g., hypertension) or the management of treatment side effects (e.g., pain). Oral chemotherapies from PAPs were significantly more likely to be for breast versus other cancers, and be a newer, targeted versus traditional chemotherapy.^ Conclusions. In outpatient settings, PAP enrollment assistance plus additional medication services (e.g., counseling, reminders, and free samples) is associated with improved disease indicators for patients. Healthcare institutions, including cancer centers, can offset financial losses from uncompensated drug costs and recoup costs invested in enrollment assistance programs by procuring free PAP medications. Cancer patients who are indigent and uninsured may be able to access more outpatient medications for their supportive care needs through PAPs, than for cancer treatment options like oral chemotherapies. Because of the selective availability of drugs through PAPs, there may be more options for newer, oral, targeted chemotherapies for the treatment breast cancer versus other for other cancers.^

Pregnancy intention, intimate partner violence, and the use of prenatal care in Jordan

Previous research has suggested an association between intimate partner violence and pregnancy intention status, and pregnancy intention status and the use of prenatal care services, however much of these studies have been conducted in high income countries (HIC) rather than low and middle income countries (LMIC). The objectives of this study were to examine the relationship between pregnancy intention status and intimate partner violence, and pregnancy intention status and the use of prenatal care among ever-married women in Jordan.^ Data were collected from a nationally representative sample of women interviewed in the 2007 Jordan Demographic and Health Survey. The sample was restricted to ever-married women, 15–49 years of age, who had a live birth within the five years preceding the survey. Multivariate logistic regression analyses was used to determine the relationship between intimate partner violence and pregnancy intention status, and pregnancy intention status and the use of prenatal care services.^ Women who reported a mistimed pregnancy (PORadj 1.96, 95% CI: 1.31–2.95), as well as an unwanted pregnancy (PORadj 1.32, 95% CI: 0.80–2.18) had a higher odds of experiencing lifetime physical and/or sexual abuse compared with women reporting a wanted pregnancy. Women not initiating prenatal care by the end of the first trimester had statistically significant higher odds of reporting both a mistimed (PORadj 2.07, 95% CI: 1.55–2.77) and unwanted pregnancy (PORadj 2.36, 95% CI: 1.68–3.31), compared with women initiating care in the first trimester. Additionally, women not receiving the adequate number of prenatal care visits for their last pregnancy had a higher odds of reporting an unwanted pregnancy (PORadj 2.11, 95% CI: 1.35–3.29) and mistimed pregnancy (POR adj 1.41, 95% CI: 0.96–2.07).^ Reducing intimate partner violence may decrease the prevalence of mistimed or unwanted pregnancies, and reducing both unwanted and mistimed pregnancies may decrease the prevalence of women not receiving timely and adequate prenatal care among women in this population. Further research, particularly in LMIC, is needed regarding the determinants of unintended pregnancy and its association with intimate partner violence as well as with the use of prenatal care services. ^

Ethnographic and epidemiologic approaches for the programming of prenatal and birth services in Mesa los Hornos, Mexico

The investigator conducted an action-oriented investigation of pregnancy and birth among the women of Mesa los Hornos, an urban squatter slum in Mexico City. Three aims guided the project: (1) To obtain information for improving prenatal and maternity service utilization; (2) To examine the utility of rapid ethnographic and epidemiologic assessment methodologies; (3) To cultivate community involvement in health development.^ Viewing service utilization as a culturally-bound decision, the study included a qualitative phase to explore women's cognition of pregnancy and birth, their perceived needs during pregnancy, and their criteria of service acceptability. A probability-based community survey delineated parameters of service utilization and pregnancy health events, and probed reasons for decisions to use medical services, lay midwives, or other sources of prenatal and labor and delivery assistance. Qualitative survey of service providers at relevant clinics, hospitals, and practices contributed information on service availability and access, and on coordination among private, social security, and public assistance health service sectors. The ethnographic approach to exploring the rationale for use or non-use of services provided a necessary complement to conventional barrier-based assessment, to inform planning of culturally appropriate interventions.^ Information collection and interpretation was conducted under the aegis of an advisory committee of community residents and service agency representatives; the residents' committee formulated recommendations for action based on findings, and forwarded the mandate to governmental social and urban development offices. Recommendations were designed to inform and develop community participation in health care decision-making.^ Rapid research methods are powerful tools for achieving community-based empowerment toward investigation and resolution of local health problems. But while ethnography works well in synergy with quantitative assessment approaches to strengthen the validity and richness of short-term field work, the author strongly urges caution in application of Rapid Ethnographic Assessments. An ethnographic sensibility is essential to the research enterprise for the development of an active and cooperative community base, the design and use of quantitative instruments, the appropriate use of qualitative techniques, and the interpretation of culturally-oriented information. However, prescribed and standardized Rapid Ethnographic Assessment techniques are counter-productive if used as research short-cuts before locale- and subject-specific cultural understanding is achieved. ^

Resilience in Cloud Computing for Critical Systems. Resilience, Dependability, Reliability in the use of Cloud Computing in Critical Systems in Public Organizations.

La informática se está convirtiendo en la quinta utilidad (gas, agua, luz, teléfono) en parte debido al impacto de Cloud Computing en las mayorías de las organizaciones. Este uso de informática es usada por cada vez más tipos de sistemas, incluidos Sistemas Críticos. Esto tiene un impacto en la complejidad internad y la fiabilidad de los sistemas de la organización y los que se ofrecen a los clientes. Este trabajo investiga el uso de Cloud Computing por sistemas críticos, centrándose en las dependencias y especialmente en la fiabilidad de estos sistemas. Se han presentado algunos ejemplos de su uso, y aunque su utilización en sistemas críticos no está extendido, se presenta cual puede llegar a ser su impacto. El objetivo de este trabajo es primero definir un modelo que pueda representar de una forma cuantitativa las interdependencias en fiabilidad y interdependencia para las organizaciones que utilicen estos sistemas, y aplicar este modelo en un sistema crítico del campo de sanidad y mostrar sus resultados. Los conceptos de “macro-dependability” y “micro-dependability” son introducidos en el modelo para la definición de interdependencia y para analizar la fiabilidad de sistemas que dependen de otros sistemas. ABSTRACT With the increasing utilization of Internet services and cloud computing by most organizations (both private and public), it is clear that computing is becoming the 5th utility (along with water, electricity, telephony and gas). These technologies are used for almost all types of systems, and the number is increasing, including Critical Infrastructure systems. Even if Critical Infrastructure systems appear not to rely directly on cloud services, there may be hidden inter-dependencies. This is true even for private cloud computing, which seems more secure and reliable. The critical systems can began in some cases with a clear and simple design, but evolved as described by Egan to "rafted" networks. Because they are usually controlled by one or few organizations, even when they are complex systems, their dependencies can be understood. The organization oversees and manages changes. These CI systems have been affected by the introduction of new ICT models like global communications, PCs and the Internet. Even virtualization took more time to be adopted by Critical systems, due to their strategic nature, but once that these technologies have been proven in other areas, at the end they are adopted as well, for different reasons such as costs. A new technology model is happening now based on some previous technologies (virtualization, distributing and utility computing, web and software services) that are offered in new ways and is called cloud computing. The organizations are migrating more services to the cloud; this will have impact in their internal complexity and in the reliability of the systems they are offering to the organization itself and their clients. Not always this added complexity and associated risks to their reliability are seen. As well, when two or more CI systems are interacting, the risks of one can affect the rest, sharing the risks. This work investigates the use of cloud computing by critical systems, and is focused in the dependencies and reliability of these systems. Some examples are presented together with the associated risks. A framework is introduced for analysing the dependability and resilience of a system that relies on cloud services and how to improve them. As part of the framework, the concepts of micro and macro dependability are introduced to explain the internal and external dependability on services supplied by an external cloud. A pharmacovigilance model system has been used for framework validation.

Evaluation of an integrated system for classification, assessment and comparison of services for long-term care in Europe: the eDESDE-LTC study

Background: The harmonization of European health systems brings with it a need for tools to allow the standardized collection of information about medical care. A common coding system and standards for the description of services are needed to allow local data to be incorporated into evidence-informed policy, and to permit equity and mobility to be assessed. The aim of this project has been to design such a classification and a related tool for the coding of services for Long Term Care (DESDE-LTC), based on the European Service Mapping Schedule (ESMS). Methods: The development of DESDE-LTC followed an iterative process using nominal groups in 6 European countries. 54 researchers and stakeholders in health and social services contributed to this process. In order to classify services, we use the minimal organization unit or “Basic Stable Input of Care” (BSIC), coded by its principal function or “Main Type of Care” (MTC). The evaluation of the tool included an analysis of feasibility, consistency, ontology, inter-rater reliability, Boolean Factor Analysis, and a preliminary impact analysis (screening, scoping and appraisal). Results: DESDE-LTC includes an alpha-numerical coding system, a glossary and an assessment instrument for mapping and counting LTC. It shows high feasibility, consistency, inter-rater reliability and face, content and construct validity. DESDE-LTC is ontologically consistent. It is regarded by experts as useful and relevant for evidence-informed decision making. Conclusion: DESDE-LTC contributes to establishing a common terminology, taxonomy and coding of LTC services in a European context, and a standard procedure for data collection and international comparison.

Towards Better Use of Credit Reporting in Europe. CEPS-ECRI Task Force Report, September 2013

This report discusses how the current EU credit reporting systems meet the demands of the different stakeholders in the credit granting and management process, and what is needed to improve these systems. As credit reporting is a tool for responsible lending and for ensuring financial inclusion of consumers, it argues that the needs of EU credit markets and consumers should be the basis for assessing the current regulation and its functionality. How a creditor assesses the risk and the creditworthiness of a customer is at the core of successful and safe crediting. Facilitating this assessment process, within the boundaries of data protection laws, is a key building block for making well-informed credit decisions.

What’s the use of a transatlantic free trade area? Jean Monnet Policy Brief 05/2014

For many of those who remember the hostile EU-US trade relations of the 1980’s and the various trade disputes that have emerged between these two trade partners since then, the opening of negotiations on a joint free trade area would be good news. Strengthened trade cooperation between the partners holds the promise of expanding their mutual exchange of goods and services, not the least by solving obstacles to integration on less transparent issues such as the extent to which product characteristics should be defined by their regional characteristics (e.g. can Budweiser be produced outside the Budweis region in the Czech Republic?).

Use of safety restraints by law enforcement officers following safety belt training and passage of a state-wide belt law. Final report.

National Highway Traffic Safety Administration, Washington, D.C.

Handbook on the use of vaccines and sera,

Original title (romanized): Spravochnik po primeneniyu vaktsin i syvorotok.

Jobs in the private sector : use of labor market information : a user's guide with detailed appendices /

"October 1980."

The use of computers in literature searching and related reference activities in libraries : papers presented at the 1975 Clinic on Library Applications of Data Processing, April 27-30, 1975 /

Includes bibliographical references.

Narrative of services in the liberation of Chili, Peru, and Brazil, from Spanish and Portuguese domination,

The author was commander of the Chilean navy 1818-1823, and held a like position in Brazil, 1823-1825.

Instruction in the use of books and libraries in colleges and universities.

Mode of access: Internet.

The use of economic data in collective bargaining /

Supplement to manual of same title.

Urban-fringe problem in the Flint metropolitan area; a study of services and attitudes

Mode of access: Internet.