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Streamlining the supply chain.
Neumann L.
Supply Chain Transformation Services, Cap Gemini Ernst & Young Health,
Chicago, USA. lydon.neumann@cgey.com
Effective management of the supply chain requires attention to: Product
management--formulary development and maintenance, compliance, clinical
involvement, standardization, and demand-matching. Sourcing and
contracting--vendor consolidation, GPO portfolio management, price
leveling, content management, and direct contracting Purchasing and
payment-cycle--automatic placement, web enablement, centralization,
evaluated receipts settlement, and invoice matching Inventory and
distribution management--"unofficial" and "official" locations,
vendor-managed inventory, automatic replenishment, and freight
management.
PMID: 12866156 [PubMed - in process]
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Use of pharmacoeconomics in prescribing research.
Part 3: Cost-effectiveness analysis--a technique for decision-making at
the margin.
Lopert R, Lang DL, Hill SR.
Pharmaceutical Benefits Branch, Department of Health and Ageing,
Canberra, ACT, Australia. ruth.lopert@health.gov.au
This is the third Research Note addressing pharmacoeconomics in
prescribing research, reflecting the increasing use of economic
evaluation in drug purchasing decisions in a variety of settings. In
this segment we provide an overview of the theoretical basis, practical
application and methodological limitations of cost-effectiveness
analysis (CEA).
PMID: 12795784 [PubMed - in process]
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Do consumers' attitudes predict prescription
purchasing behavior?
Nair KV.
School of Pharmacy, University of Colorado Health Sciences Center,
Denver, USA.
Consumers may face prescription choices in three-tier plans, primarily
between lower-cost generic drugs, formulary (tier 2) brands, and
higher-cost nonformulary (tier 3) brands. To determine if consumers'
beliefs about medications influence their prescription choices, a
preliminary evaluation of the effect of such beliefs on prescription
purchasing behavior was conducted in an MCO population. Attitudes about
prescription drug coverage and perceptions regarding medications had no
demonstrated effect on formulary compliance or rates of discontinuation
of nonformulary medications. The findings appear to support the concept
of three-tier plans, and increasing copayments seems to facilitate
greater adherence to health plan formularies.
PMID: 12841073 [PubMed - in process]
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Do house officers learn from their mistakes?
Wu AW, Folkman S, McPhee SJ, Lo B.
Department of Medicine, University of California, San Francisco, USA.
Mistakes are inevitable in medicine. To learn how medical mistakes
relate to subsequent changes in practice, we surveyed 254 internal
medicine house officers. One hundred and fourteen house officers (45%)
completed an anonymous questionnaire describing their most significant
mistake and their response to it. Mistakes included errors in diagnosis
(33%), prescribing (29%), evaluation (21%), and communication (5%) and
procedural complications (11%). Patients had serious adverse outcomes in
90% of the cases, including death in 31% of cases. Only 54% of house
officers discussed the mistake with their attending physicians, and only
24% told the patients or families. House officers who accepted
responsibility for the mistake and discussed it were more likely to
report constructive changes in practice. Residents were less likely to
make constructive changes if they attributed the mistake to job
overload. They were more likely to report defensive changes if they felt
the institution was judgmental. Decreasing the work load and closer
supervision may help prevent mistakes. To promote learning, faculty
should encourage house officers to accept responsibility and to discuss
their mistakes.
MeSH Terms:
- Health Services Research
- Human
- Interdisciplinary Communication
- Internal Medicine/education*
- Learning*
- Medical Errors/prevention & control*
- Medical Staff, Hospital/education*
- Outcome Assessment (Health Care)
- Quality Assurance, Health Care/organization & administration
- Questionnaires
- Risk Reduction Behavior
- Social Responsibility
- Support, Non-U.S. Gov't
- Support, U.S. Gov't, Non-P.H.S.
- Support, U.S. Gov't, P.H.S.
- Truth Disclosure
- Workload
Grant Support:
PMID: 12792014 [PubMed - indexed for MEDLINE]
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A statistical analysis of the magnitude and
composition of drug promotion in the United States in 1998.
Ma J, Stafford RS, Cockburn IM, Finkelstein SN.
Stanford Center for Research in Disease Prevention, Stanford University,
Palo Alto, California 94304, USA.
BACKGROUND: Although pharmaceutical industry marketing and other factors
may influence physician decisions regarding medication prescribing in
the United States, little information is available about the composition
of promotional efforts by promotional mode and medication class.
OBJECTIVES: The aims of this study were to determine the magnitude of
expenditures for common modes of promotion and to delineate patterns of
promotional strategies for particular classes of medications. METHODS:
Nationally representative data on expenditures (in US $) for the 250
most promoted medications in the United States in 1998 were available
from an independent pharmaceutical market research company for the 5
most commonly used modes of promotion. Key patterns of drug promotion
were identified by descriptive statistics, a cluster analysis of
expenditures by class, and an analysis of expenditure concentration.
RESULTS: In 1998, the pharmaceutical industry spent $12,724 million
promoting its products in the United States, of which 85.9% was
accounted for by the top 250 drugs and 51.6% by the top 50 drugs.
Direct-to-consumer (DTC) advertising was more concentrated on a small
subset of medications than was promotion to professionals. Overall, 1998
expenditures were dominated by free drug samples provided to physicians
(equivalent retail cost of $6602 million) and office promotion ($3537
million), followed by DTC advertising ($1337 million), hospital
promotion ($705 million), and advertising in medical journals ($540
million). Four distinct patterns of expenditures were observed:
promotion to office physicians with little consumer promotion (14 drug
classes); dual focus on office physicians and consumer advertising (4
drug classes); predominant DTC advertising (1 class: smoking-cessation
products); and promotion to office- and hospital-based professionals
without consumer advertising (1 class: narcotic analgesics).
CONCLUSIONS: The present findings reinforce the perception that the
pharmaceutical industry invests heavily in promoting its products and
demonstrates that promotional expenditures are concentrated on a small
number of medications. Although promotion to professionals remains
dominant, DTC advertising has become key for a subset of common
medications
Grant Support:
PMID: 12867225 [PubMed - in process]
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The impact of a national prescription drug formulary
on prices, market share, and spending: lessons for Medicare?
Huskamp HA, Epstein AM, Blumenthal D.
Department of Health Care Policy, Harvard Medical School, USA.
Several recent bills in Congress to add a Medicare prescription drug
benefit would allow the use of formularies to control costs. However,
there is little empirical evidence of the impact of formularies among
elderly and disabled populations. We assess the effect of a closed
formulary implemented by the Veterans Health Administration (VHA) in
1997 on drug prices, market share, and drug spending. We find that the
VHA National Formulary was effective at shifting prescribing behavior
toward the selected drugs, achieving sizable price reductions from
manufacturers, and greatly decreasing drug spending.
Publication Types:
MeSH Terms:
- Aged
- Cost Control/methods
- Drug Costs/statistics & numerical data*
- Drug Utilization
- Female
- Formularies*
- Health Care Sector
- Health Expenditures/statistics & numerical data
- Human
- Insurance, Pharmaceutical Services*
- Male
- Medicare/economics
- Medicare/organization & administration
- Middle Age
- Physician's Practice Patterns
- Prescriptions, Drug/economics*
- Quality of Health Care
- Support, Non-U.S. Gov't
- Support, U.S. Gov't, P.H.S.
- United States
- United States Department of Veterans Affairs/organization &
administration*
Grant Support:
- 1 K01 MH 66109/MH/NIMH
- 5 P01 HS10803-2/HS/AHCPR
PMID: 12757279 [PubMed - indexed for MEDLINE]
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[Computerized decision support in drug prescribing
II: A national database to provide up-to-date and unbiased information]
[Article in Swedish]
Gustafsson LL, Widang K, Hoffmann M, Andersen-Karlsson E, Elfman K,
Johansson B, Johansson E, Larson M.
Avdelningen for klinisk farmakologi, Karolinska institutet, Huddinge
Universitetssjukhus. lars-l.gustafsson@labmed.ki.se
Prescribers today encounter increasing demands for up-to-date knowledge
of medical advances and drug therapies, and for a straightforward
dialogue with patients. Cost-effective drug treatment calls for fast and
intuitive access to information about drugs, treatment strategies and
patient data. There are several computer-based drug-prescribing systems
in Sweden. Information independent of the drug industry is wanting, as
are uniform national standards for medical content and functionality.
Decision-support systems must facilitate decisions about therapy, drug
distribution and intake, as well as quality work, i.e. support the
entire process which defines an effective drug therapy. A very important
feature is access to a patient's drug list showing all current drugs.
This joint initiative by county councils aims at drawing up a national
Swedish specification of requirements for a suitable decision-support
system and at creating a national entity responsible for distributing
unbiased information from a unique database to a range of computerized
medical records systems.
MeSH Terms:
- Catalogs, Drug
- Clinical Pharmacy Information Systems*
- Databases, Factual*
- Decision Support Systems, Clinical*
- Drug Information Services
- English Abstract
- Evidence-Based Medicine
- Human
- Patient Education
- Polypharmacy
- Practice Guidelines
- Prescriptions, Drug*/standards
- Sweden
PMID: 12739404 [PubMed - indexed for MEDLINE]
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A cost-benefit analysis of electronic medical records
in primary care.
Wang SJ, Middleton B, Prosser LA, Bardon CG, Spurr CD, Carchidi PJ,
Kittler AF, Goldszer RC, Fairchild DG, Sussman AJ, Kuperman GJ, Bates DW.
Department of Information Systems, Partners HealthCare System, Boston,
Massachusetts 02481, USA. sjwang@partners.org
Electronic medical record systems improve the quality of patient care
and decrease medical errors, but their financial effects have not been
as well documented. The purpose of this study was to estimate the net
financial benefit or cost of implementing electronic medical record
systems in primary care. We performed a cost-benefit study to analyze
the financial effects of electronic medical record systems in ambulatory
primary care settings from the perspective of the health care
organization. Data were obtained from studies at our institution and
from the published literature. The reference strategy for comparisons
was the traditional paper-based medical record. The primary outcome
measure was the net financial benefit or cost per primary care physician
for a 5-year period. The estimated net benefit from using an electronic
medical record for a 5-year period was 86,400 US dollars per provider.
Benefits accrue primarily from savings in drug expenditures, improved
utilization of radiology tests, better capture of charges, and decreased
billing errors. In one-way sensitivity analyses, the model was most
sensitive to the proportion of patients whose care was capitated; the
net benefit varied from a low of 8400 US dollars to a high of 140,100 US
dollars . A five-way sensitivity analysis with the most pessimistic and
optimistic assumptions showed results ranging from a 2300 US dollars net
cost to a 330,900 US dollars net benefit. Implementation of an
electronic medical record system in primary care can result in a
positive financial return on investment to the health care organization.
The magnitude of the return is sensitive to several key factors.
Copyright 2003 by Excerpta Medica Inc.
MeSH Terms:
- Computers/economics
- Cost-Benefit Analysis
- Drug Costs
- Efficiency
- Human
- Medical Records Systems, Computerized/economics*
- Office Management/economics*
- Primary Health Care/economics*
- Sensitivity and Specificity
- Software/economics
PMID: 12714130 [PubMed - indexed for MEDLINE]
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Do clinical practice education groups result in
sustained change in GP prescribing?
Richards D, Toop L, Graham P.
Department of Public Health and General Practice, Christchurch School of
Medicine, University of Otago, PO Box 4345, Christchurch, New Zealand.
BACKGROUND: Concern has been expressed at the poor uptake of evidence
into clinical practice. This is despite the fact that continuing
education is an embedded feature of quality assurance in general
practice. There are a variety of clinical practice education methods
available for dissemination of new evidence. Recent systematic reviews
indicate that the effectiveness of these different strategies is
extremely variable. OBJECTIVE: Our aim was to determine whether a
peer-led small group education pilot programme used to promote rational
GP prescribing is an effective tool in changing practice when added to
prescribing audit and feedback, academic detailing and educational
bulletins, and to determine whether any effect seen decays over time.
METHODS: A retrospective analysis of a controlled trial of a small group
education strategy with 24 month follow-up was carried out. The setting
was an independent GPs association (IPA) of 230 GPs in the Christchurch
New Zealand urban area. All intervention and control group GPs were
already receiving prescribing audit and feedback, academic detailing and
educational bulletins. The intervention group were the first 52 GPs to
respond to an invitation to pilot the project. Two control groups were
used, one group who joined the pilot later and a second group which
included all other GPs in the IPA. The main outcome measures were
targeted prescribing data for 12 months before and 24 months after each
of four education sessions. RESULTS: An effect in the expected direction
was seen in six of the eight key messages studied. This effect was
statistically significant for five of the eight messages studied. The
effect size varied between 7 and 40%. Where a positive effect was seen,
the effect decayed with time but persisted to a significant level for
6-24 months of observation. CONCLUSION: The results support a positive
effect of the education strategy on prescribing behaviour in the
intervention group for most outcomes measured. The effect seen is
statistically significant, sustained and is in addition to any effect of
the other pharmaceutical educational initiatives already undertaken by
the IPA.
PMID: 12651796 [PubMed - in process]
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Comment in:
Doctors' perceptions and attitudes to prescribing
within the Authority Prescribing System.
Liaw ST, Pearce CM, Chondros P, McGrath BP, Piggford L, Jones K.
Department of General Practice, The University of Melbourne, 200
Berkeley Street, Carlton, Victoria 3053, Australia. t.liaw@unimelb.edu.au
OBJECTIVE: To examine doctors' perceptions and attitudes to prescribing
within the Authority Prescribing System (APS). DESIGN AND SETTING:
Questionnaire survey of Australian doctors' responses to a number of
statements and factorial vignettes, conducted between 1 May and 30 June
2001. PARTICIPANTS: A national random sample of 1200 doctors, stratified
according to specialist/generalist, rural/urban and high/low prescriber:
669 (56%) responded. MAIN OUTCOME MEASURES: Self-reported perceptions of
the APS and attitudes to prescribing within the APS. RESULTS: 72% of
doctors agreed that the APS makes effective medications available to the
socioeconomically disadvantaged members of the Australian public and 50%
agreed that it compromises patient privacy. Fewer agreed that authority
indicators were based on the highest quality of evidence quality (40%)
or medication safety (12%). Doctors placed more emphasis on the
doctor-patient relationship than on the criteria for authority
prescribing in their decisions about prescribing APS medications.
Doctors who used computers to prescribe were more likely to agree that
computers can improve the authority prescribing process. CONCLUSIONS:
This study suggests that authority-required prescribing is not achieving
the stated aims of the National Medicines Policy in reducing variability
in prescribing. Strategies to improve the quality of prescribing must
consider the professional and ethical conundrum associated with
prescribing outside of PBS/APS approved use for clinical and patient-centred
reasons.
MeSH Terms:
- Adult
- Attitude of Health Personnel
- Australia
- Cost Control
- Drug Costs
- Drug and Narcotic Control*
- Female
- Health Care Surveys
- Health Policy*
- Human
- Insurance Coverage
- Insurance, Pharmaceutical Services*
- Male
- Physician's Practice Patterns/statistics & numerical data*
- Prescriptions, Drug*
- State Medicine*
- Support, Non-U.S. Gov't
PMID: 12603181 [PubMed - indexed for MEDLINE]
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Cost to the patient or cost to the healthcare system?
Which one matters the most for GP prescribing decisions? A UK-Italy
comparison.
Hassell K, Atella V, Schafheutle EI, Weiss MC, Noyce PR.
School of Pharmacy and Pharmaceutical Sciences, University of
Manchester, Manchester, United Kingdom. Karen.Hassell@man.ac.uk
BACKGROUND: Charges for health services help contain healthcare costs.
Despite showing that medicine consumption decreases when charges are
increased there is little research that illuminates how doctors 'manage'
the charge system to help patients who cannot afford treatment. This
paper describes how the charge system influences the prescribing
decisions of Italian and UK physicians. METHODS: The data are from the
qualitative stage of a multi-stage study exploring cost related
influences on GP and patient decision-making regarding medicine use. The
analysis presented is based on transcripts of focus groups conducted
with general practitioners. RESULTS: To help patients who have
difficulties affording their medication Italian GPs rely on a smaller
number of cost reduction strategies compared to their UK counterparts.
They use 'samples' left by pharmaceutical companies, or diagnose
patients with pathologies that allow exemption. Occasionally they
recommend some delay or change therapy to a cheaper but less effective
alternative. Italian and UK GPs have firm views about preventing
patients abusing the NHS and believe costs to the system are as
important as costs to the individual patient. Prescribing budgets were
not viewed in a positive light by Italian GPs. CONCLUSION: Due to the
nature of the charge system in Italy GPs there are able to choose a
reimbursable product for patients, so have less need than UK doctors to
look for other means of reducing costs. Conversely, the UK GPs have
developed a large number of cost reduction strategies, probably because
of the charge system itself and the relatively high charges incurred by
patients.
MeSH Terms:
- Adult
- Aged
- Comparative Study
- Cost Sharing
- Decision Making*
- Drug Utilization/economics*
- Female
- Focus Groups
- Great Britain
- Health Care Costs*
- Health Services Research
- Human
- Italy
- Male
- Middle Age
- Physician's Practice Patterns/economics
- Physicians, Family/psychology*
- Prescription Fees*
- Support, Non-U.S. Gov't
PMID: 12678309 [PubMed - indexed for MEDLINE]
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A qualitative study to explore influences on general
practitioners' decisions to prescribe new drugs.
Jacoby A, Smith M, Eccles M.
Department of Primary Care, Whelan Building, The Quadrangle, Brownlow
Hill, Liverpool, L69 3GB. ajacoby@liv.ac.uk
BACKGROUND: Ensuring appropriate prescribing is an important challenge
for the health service, and the need for research that takes account of
the reasons behind individual general practitioners' (GPs) prescribing
decisions has been highlighted. AIM: To explore differences among GPs in
their decisions to prescribe new drugs. DESIGN OF STUDY: Qualitative
approach, using in-depth semistructured interviews. SETTING: Northern
and Yorkshire Health Authority Region. METHOD: Participants were
identified from a random sample of 520 GPs in a quantitative study of
patterns of uptake of eight recently introduced drugs. Purposeful
sampling ensured inclusion of GPs prescribing any of the eight drugs and
working in a range of practice settings. Fifty-six GPs were interviewed,
using a topic guide. Interviews were recorded on audiotape. Transcribed
text was methodically coded and data were analysed by constantly
comparing emerging themes. RESULTS: Both low and high prescribers shared
a view of themselves as conservative in their prescribing behaviour. Low
prescribers appeared to conform more strongly to group norms and
identified a consensus among practice partners in prescribing and
cost-consciousness. Conformism to group norms was represented by a
commitment to practice formularies. High prescribers more often
expressed themselves to be indifferent to drug costs and a shared
practice ethos. CONCLUSIONS: A shift in the attitudes of some GPs is
required before cost-effectiveness is routinely incorporated in drug
prescribing. The promotion of rational prescribing is likely to be more
successful if efforts are focused on GPs' appreciation of cost issues
and attitudes towards shared decision-making and responsibility.
MeSH Terms:
- Attitude of Health Personnel*
- Decision Making
- Drug Costs
- Drug Utilization Review*
- England
- Human
- Physician's Practice Patterns/economics
- Physician's Practice Patterns/standards*
- Physicians, Family/economics
- Physicians, Family/standards*
- Physicians, Family/statistics & numerical data
- Qualitative Research
- Support, Non-U.S. Gov't
PMID: 12817357 [PubMed - indexed for MEDLINE]
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Influences on GPs' decision to prescribe new
drugs-the importance of who says what.
Prosser H, Almond S, Walley T.
Prescribing Research Group, Department of Pharmacology, The Infirmary,
70 Pembroke Place, Liverpool L69 3GF, UK. H.Prosser@liverpool.ac.uk
OBJECTIVES: The aim of this study was to understand the range of factors
that influence GPs' uptake of new drugs METHODS: A total of 107 GPs
selected purposively from high, medium and low new drug prescribing
practices in two health authorities in the north west of England were
interviewed using the critical incident technique with semi-structured
interviews. Interview topics included reasons for prescribing new drugs
launched between January 1998 and May 1999; reasons for prescribing the
new drug rather than alternatives; and sources of information used for
each prescribed drug. RESULTS: Important biomedical influences were the
failure of current therapy and adverse effect profile. More influential
than these, however, was the pharmaceutical representative. Hospital
consultants and observation of hospital prescribing was cited next most
frequently. Patient request for a drug, and patient convenience and
acceptability were also likely to influence new drug uptake. Written
information was of limited importance except for local guidelines. GPs
were largely reactive and opportunistic recipients of new drug
information, rarely reporting an active information search. The decision
to initiate a new drug is heavily influenced by 'who says what', in
particular the pharmaceutical industry, hospital consultants and
patients. The decision to 'adopt' a new drug is clinched by subsequent
personal clinical experience. CONCLUSIONS: Prescribing of new drugs is
not simply related to biomedical evaluation and critical appraisal but,
more importantly, to the mode of exposure to pharmacological information
and social influences on decision making. Viewed within this broad
context, prescribing variation becomes more understandable. Findings
have implications for the implementation of evidence-based medicine,
which requires a multifaceted approach.
Publication Types:
MeSH Terms:
- Decision Making
- Drug Utilization
- England
- Family Practice*/statistics & numerical data
- Female
- Human
- Male
- Physician's Practice Patterns/statistics & numerical data*
PMID: 12509373 [PubMed - indexed for MEDLINE]
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Use of pharmacoeconomics in prescribing research.
Part 1: costs--moving beyond the acquisition price for drugs.
Robertson J, Lang D, Hill S.
Clinical Pharmacology, School of Medical Practice and Population Health,
Faculty of Health, University of Newcastle, NSW Australia. jroberts@mail.newcastle.edu.au
This paper addresses pharmacoeconomics in prescribing research and
reflects the increasing use of techniques of economic evaluation to aid
drug purchasing decisions in a variety of settings -- for national drug
subsidization programmes, provincial purchasing plans, insurance
programmes, and for hospital and area health authority formulary
decisions. First, we focus on the cost component of an economic
evaluation and discuss methodological issues that are relevant to all
pharmacoeconomic analyses.
MeSH Terms:
- Cost Control
- Cost-Benefit Analysis
- Drug Costs
- Drug Utilization Review/methods*
- Economics, Pharmaceutical*
- Human
- Pharmaceutical Preparations/economics*
- Prescriptions, Drug
- Research Design*
Substances:
- Pharmaceutical Preparations
PMID: 12605622 [PubMed - indexed for MEDLINE]
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Does a doctor have a duty to provide information and
advice about complementary and alternative medicine?
Brophy E.
ebrophy@vicbar.com.au
It is argued that a doctor has a duty to provide information about
reasonably available complementary and alternative medicine treatments
where that information would be material to the particular patient or
the hypothetical prudent patient. Given the vast array of such
treatments available, doctors will want to rely on evidence-based
medicine problem-solving skills to ascertain those treatments that are
safe and efficacious. While the risk of litigation for failure to
provide such information is probably low at this time, given the high
rate of patient self-prescribing, it is necessary for a doctor to open a
dialogue with a patient about complementary and alternative medicine to
address safety concerns. In addition, it is important to facilitate
access to the best of conventional and complementary treatments to
ensure better health outcomes for the patient.
MeSH Terms:
- Australia
- Complementary Therapies/legislation & jurisprudence*
- Complementary Therapies/standards
- Counseling/legislation & jurisprudence
- Decision Making
- Evidence-Based Medicine*
- Human
- Information Dissemination/ethics*
- Information Dissemination/legislation & jurisprudence*
- Informed Consent/ethics*
- Informed Consent/legislation & jurisprudence*
- Moral Obligations*
- Patient Education/ethics*
- Patient Education/legislation & jurisprudence*
- Patient Participation
- Patient Rights/legislation & jurisprudence
- Physician's Role
- Physician-Patient Relations
- Societies, Medical
PMID: 12649999 [PubMed - indexed for MEDLINE]
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Comment in:
Attitudes and behaviour of general practitioners and
their prescribing costs: a national cross sectional survey.
Watkins C, Harvey I, Carthy P, Moore L, Robinson E, Brawn R.
General Practitioner, Backwell and Nailsea Medical Group, Backwell,
Bristol BS48 3HA, UK. chris.watkins@bristol.ac.uk
BACKGROUND: General practitioner (GP) prescribing accounts for about 10%
of NHS expenditure. GPs at the top of the range have annual prescribing
costs that are almost twice as much as those at the bottom of the range.
This variation cannot be accounted for purely in terms of differences in
underlying need for health care. OBJECTIVES: To describe the
relationship between GPs' prescribing costs and their attitudes towards
prescribing decisions and prescribing information sources, and to
identify potentially modifiable attitudinal and behavioural factors
associated with high cost prescribing. DESIGN: A postal questionnaire
was designed on the basis of hypotheses developed from a literature
search and an earlier qualitative survey. This questionnaire was sent to
a national sample of GPs with equal numbers of practices in the upper,
middle, and lowest quintile of prescribing costs. SETTING: GP practices
in England. PARTICIPANTS: 1714 GPs in NHS practice. OUTCOME MEASURES:
GPs' self-reported practices, attitudes and personal characteristics.
RESULTS: There was a 64% response rate. Responders were more likely to
be from larger practices, in less deprived areas, and with lower
prescribing costs than were non-responders. Multivariable analysis
showed that GPs with high prescribing costs were significantly more
likely to work in dispensing practices, in practices with low income
populations, in single handed practices, and in practices without a GP
trainer. They were also significantly more likely to see drug company
representatives more frequently, to prescribe newly available drugs more
freely, to prescribe more readily to patients who expect a prescription,
to report high levels of frustration from lack of time in the
consultation, to find unsatisfactory those consultations which ended in
advice only, and to express dissatisfaction with their review methods
for repeat prescribing. They were significantly less likely to find
useful criticism of prescribing habits by colleagues, and to check the
BNF rather than other sources when uncertain about an aspect of drug
treatment. CONCLUSIONS: While they cannot be held to have a causal
relationship, the pattern of attitudes towards prescribing of GPs in the
highest quintile of prescribing costs provide the basis for developing
an educational intervention which may be an acceptable method of
modifying the attitudes of GPs and consequently reducing their
prescribing costs.
MeSH Terms:
- Attitude of Health Personnel*
- Cross-Sectional Studies
- Drug Utilization/economics*
- Female
- Germany
- Great Britain
- Health Care Surveys
- Health Expenditures
- Human
- Male
- Physician's Practice Patterns/economics*
- Physician's Practice Patterns/statistics & numerical data
- Physicians, Family/psychology*
- Prescriptions, Drug/economics*
- Prescriptions, Drug/statistics & numerical data
- Questionnaires
- State Medicine/economics
- Support, Non-U.S. Gov't
PMID: 12571342 [PubMed - indexed for MEDLINE]
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Comment in:
 
Why do general practitioners prescribe antibiotics
for sore throat? Grounded theory interview study.
Kumar S, Little P, Britten N.
Department of Primary Medical Care, University of Southampton,
Southampton SO17 3RT. skk@soton.ac.uk
OBJECTIVES: To understand why general practitioners prescribe
antibiotics for some cases of sore throat and to explore the factors
that influence their prescribing. DESIGN: Grounded theory interview
study. SETTING: General practice. PARTICIPANTS: 40 general
practitioners: 25 in the maximum variety sample and 15 in the
theoretical sample. RESULTS: General practitioners are uncertain which
patients will benefit from antibiotics but prescribe for sicker patients
and for patients from socioeconomically deprived backgrounds because of
concerns about complications. They are also more likely to prescribe in
pressured clinical contexts. Doctors are mostly comfortable with their
prescribing decisions and are not prescribing to maintain the
doctor-patient relationship. CONCLUSIONS: General practitioners have
reduced prescribing for sore throat in response to research and policy
initiatives. Further interventions to reduce prescribing would need to
improve identification of patients at risk of complications and be
workable in busy clinical situations.
Publication Types:
MeSH Terms:
- Antibiotics/therapeutic use*
- Attitude of Health Personnel
- Decision Making
- Family Practice/methods*
- Female
- Human
- Male
- Pharyngitis/drug therapy*
- Physician's Practice Patterns*
- Physician-Patient Relations
- Physicians, Family/psychology
- Support, Non-U.S. Gov't
Substances:
PMID: 12531847 [PubMed - indexed for MEDLINE]
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Developing an effective generic prescription drug
program.
Jones JD.
Pharmacy benefit managers (PBMs) use a variety of pricing strategies.
When employers have a thorough knowledge of those strategies, they can
use them to their advantage to help manage pharmacy benefits. This
article discusses PBM strategies in terms of what employers need to
know, the questions employers need to ask and goals employers must keep
in mind in order to secure the affordable cost and quality prescription
drug management programs that they and their employees need and deserve.
MeSH Terms:
- Cost Savings
- Drugs, Generic/economics*
- Formularies
- Health Benefit Plans, Employee/economics
- Health Benefit Plans, Employee/organization & administration*
- Human
- Insurance, Pharmaceutical Services*
- Program Development
- Rate Setting and Review
- United States
Substances:
PMID: 12608114 [PubMed - indexed for MEDLINE]
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Approaches to pharmacy benefit management and the
impact of consumer cost sharing.
Olson BM.
The University of Arizona, College of Pharmacy, Center for Health
Outcomes and PharmacoEconomic Research, Tucson, Arizona 85721-0207, USA.
BACKGROUND: Numerous mechanisms have been introduced to deliver
prescription drug benefits while controlling pharmaceutical costs. An
understanding of the most prominent mechanisms of benefit management is
an important step in determining the most effective approach to take in
future years. OBJECTIVES: The aims of this review were to illustrate the
mechanisms by which managed care has attempted to efficiently and
equitably deliver pharmacy benefits and to discuss the impact of such
programs, including consumer cost sharing. METHODS: A review of the
literature was conducted using the PreMedline and MEDLINE databases from
the years 1966 to 2002, reference lists from relevant articles, and
online sources, including news releases, conference materials, and
pharmacy benefit management reports. RESULTS: Numerous pharmacy benefit
management tools and their impact on utilization, expenditures, and
health outcomes are reviewed, including disease state management;
utilization management (ie, quantity limitations and prior
authorization); drug utilization review; formulary management (ie, open
and closed); delivery systems (ie, retail and mail order); and
mechanisms for implementing consumer cost sharing (ie, generic
incentives, multitiered copayments, and co-insurance). Although there is
some evidence to suggest that certain benefit management tools have been
successful in reducing health plan expenditures, a more thorough
investigation of their potential unintended consequences is needed.
CONCLUSIONS: Implementing adequate levels of consumer cost sharing is
necessary if employers and health plans are to continue offering
prescription drug benefits. It is important to remember, however, that
quality health care cannot be forfeited for the sake of short-term cost
savings.
Publication Types:
MeSH Terms:
- Consumer Participation
- Cost Sharing/trends*
- Drug Utilization Review
- Formularies
- Health Benefit Plans, Employee/organization & administration*
- Human
- Insurance Coverage
- Insurance, Pharmaceutical Services/economics*
- Managed Care Programs/economics*
- Medication Systems
- Prescription Fees/trends
- Prescriptions, Drug/economics
- Support, Non-U.S. Gov't
- United States
PMID: 12637125 [PubMed - indexed for MEDLINE]
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Electronic prescribing: a review of costs and
benefits.
Corley ST.
University of Virginia Health System, Charlottesville, Va 22908, USA.
drcorley@internalmedicineassoc.com
Electronic prescribing tools are currently available but most medical
practices are not using them. The literature was reviewed for data on
adverse drug events and the expected dollar savings that could occur if
these events were prevented. In addition to cost savings from improved
patient safety, the effect of these systems on formulary compliance and
drug cost savings was examined. Improved physician, nurse, and staff
efficiencies were calculated using time trial comparisons between a
paper system of handling prescription refills and a representative
electronic prescribing system. The conclusion is made that electronic
prescribing software is cost-effective for all size practices with a
more rapid return on investment in larger practices.
Publication Types:
MeSH Terms:
- Adverse Drug Reaction Reporting Systems/economics
- Ambulatory Care/economics
- Clinical Pharmacy Information Systems/economics*
- Cost Savings
- Cost-Benefit Analysis
- Efficiency, Organizational
- Formularies
- Human
- Investments
- Medical Records Systems, Computerized/economics*
- Pharmacy Service, Hospital/economics
- Prescriptions, Drug/economics*
- Safety Management
- Software/economics*
- United States
PMID: 12674393 [PubMed - indexed for MEDLINE]
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How effectively do managed care organizations
influence prescribing and dispensing decisions?
Carroll NV.
School of Pharmacy, Virginia Commonwealth University, Richmond, VA
23298, USA. nvcarrol@vcu.edu
OBJECTIVE: To examine the extent to which managed care organizations (MCOs)
use formularies, therapeutic interchange, and prior approval and to
determine how effectively these tools influence prescribing and
dispensing decisions. RESEARCH DESIGN: Literature review. PATIENTS AND
METHODS: Studies relating to effectiveness were identified through a
comprehensive literature review using the MEDLINE and International
Pharmaceutical Abstracts databases. Only peer-reviewed studies done in
outpatient settings were included. Studies measuring extent of use were
taken primarily from published and widely available marketing research
reports. RESULTS: Closed formularies were found to be effective in
decreasing the utilization, but not necessarily the cost, of
prescription drugs. Just under half of health maintenance organizations
(HMOs) and 10% of employer-sponsored health plans use closed
formularies. Prior approval programs have been shown to reduce use of
target drugs and drug costs in a small number of drug classes. Nearly
all HMOs and most employer-sponsored health plans use prior approval
programs. How extensively the programs are used is not reported. About
half of HMOs and employer-sponsored health plans use therapeutic
interchange. Voluntary programs have been shown to be successful in
staff-model HMOs. Mandatory, but not voluntary, programs have been shown
to be successful in independent practice association-model HMOs.
CONCLUSION: The literature indicates that most MCOs have had limited
success using formularies, therapeutic interchange, and prior approval
to influence prescribing and dispensing decisions. Although these tools
have been effective in some situations, their impact has been limited by
their low rate of utilization.
Publication Types:
MeSH Terms:
- Cost Control
- Drug Utilization/economics
- Drug Utilization/standards*
- Drug Utilization Review
- Formularies*
- Health Maintenance Organizations/organization & administration*
- Health Services Research
- Human
- Insurance, Pharmaceutical Services*
- Physician's Practice Patterns*
- Prescriptions, Drug
- Program Evaluation
- United States
PMID: 12500881 [PubMed - indexed for MEDLINE]
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Making "me-too" drugs benefit the public.
Nusbaum NJ.
VA Capitol Health Care Network, Martinsburg, WV, USA. NusbN@aol.com
The Food and Drug Administration (FDA), in its review of pharmaceuticals
for safety and effectiveness, has relied heavily on placebo-controlled
studies. In their prescribing practice, physicians often face clinical
decisions between several FDA-approved drugs for the same indication,
with little guidance from the FDA on the similarities or differences of
the drugs. The public could benefit if the FDA were more proactive in
declaring, when applicable, that the best available evidence does not
indicate any significant clinical advantage for a particular
FDA-approved drug compared with others.
PMID: 12487336 [PubMed - in process]
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Drug reimbursement: indicators of inappropriate
resource allocation.
Begaud B, Bergman U, Eichler HG, Leufkens HG, Meier PJ.
Department de Pharmacologie, Universite Victor Segalen Bordeaux 2,
Hopital Pellegrin, F33076 Bordeaux cedex, France. bernard.begaud@pharmaco.u-bordeaux2.fr
AIMS: In many countries, governments and third parties find themselves
paying for (reimbursing) unproven, inadequate products limiting their
ability to invest in therapies with evidence of relevant patient
benefit. We examined how three characteristics, level of therapeutic
evidence, susceptibility of inappropriate prescribing, and intercountry
variation can be used to identify inefficiencies in pharmaceutical
reimbursement among four European Union countries, Austria, Belgium, the
Netherlands and Sweden. METHODS: Specific classes of medicines were
chosen to provide useful examples of how healthcare resources could be
reallocated. A high level of therapeutic evidence was defined as a
substantial body of evidence in at least one indication with clear-cut
support of relevant patient benefit. The susceptibility of inappropriate
prescribing was defined as the likelihood of prescribing a drug outside
the scenario for which clear-cut evidence (if any) has been documented
to produce relevant benefit for the patient. The intercountry variation
represents the variation in utilization of reimbursed drugs across the
four countries. RESULTS: The combination of these characteristics
provides a useful tool for assessing appropriate reimbursement
decisions. It would be beneficial to healthcare payers as well as
patients to move resources from products that have a low level of
therapeutic evidence and a high susceptibility of inappropriate
prescribing to products with a high level of therapeutic evidence and
low susceptibility of inappropriate prescribing, and to use intercountry
variation as a signal of drug classes that should be subject to further
scrutiny. CONCLUSIONS: A method is presented to help policy-makers
identify inefficiencies in the spending of limited health care
resources, and to reallocate resources to products that have been shown
to improve patient care through evidence-based medicine.
Publication Types:
MeSH Terms:
- Austria
- Belgium
- Drug Costs
- Drug Utilization
- Evidence-Based Medicine
- Health Care Rationing/economics*
- Health Policy
- Health Services Misuse/economics*
- Human
- Netherlands
- Pharmaceutical Preparations/economics*
- Prescriptions, Drug/economics
- Reimbursement Mechanisms/economics*
- Support, Non-U.S. Gov't
- Sweden
Substances:
- Pharmaceutical Preparations
PMID: 12445033 [PubMed - indexed for MEDLINE]
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Psychopharmacologic interventions in nursing homes:
what do we know and where should we go?
Ryan JM, Kidder SW, Daiello LA, Tariot PN.
University of Rochester Medical Center, New York 14620, USA.
jmichael_ryan@urmc.rochester.edu
Psychiatric symptoms are common among individuals who live in nursing
homes, with prevalence rates ranging from 51 percent to 94 percent.
Accordingly, psychotropic medications are widely prescribed in this
setting and are the subject of considerable debate and regulation.
Current regulations arose from public and governmental concerns that
psychiatric medications were being prescribed inappropriately to frail
patients. Concern has also been raised about the absence of evidence on
which to base prescribing decisions. Nursing homes are slowly being
recognized as complex health care settings that warrant considerable
research attention. This article explores the origins of the regulation
of the use of psychotropic drugs in nursing homes, reviews controlled
trials of these drugs in nursing homes, examines the role of these
agents in adverse drug events experienced by nursing home residents, and
proposes policy and research areas that merit consideration.
Publication Types:
MeSH Terms:
- Aged
- Homes for the Aged/statistics & numerical data*
- Human
- Nursing Homes/statistics & numerical data*
- Psychotropic Drugs/therapeutic use*
Substances:
PMID: 12407268 [PubMed - indexed for MEDLINE]
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Dutch GPs' perceptions: the influence of
out-of-pocket costs on prescribing.
Kasje WN, Timmer JW, Boendermaker PM, Haaijer-Ruskamp FM.
Department of Clinical Pharmacology, Faculty of Medical Sciences,
Rational Pharmacotherapy, Northern Centre for Health Care Research,
University of Groningen, Antonius Deusinglaan 1, 9713 AV Groningen, The
Netherlands. w.n.kasje@med.rug.nl
The aim of this study was to explore the impact of out-of-pocket costs
on Dutch general practitioners' prescribing. A qualitative study using
focus groups was conducted. An open-ended topic guide was used to
elucidate the influence of out-of-pocket costs on decision making for
the treatment of dyspepsia, hay fever, hormone replacement therapy, and
hypertension. A total of 21 Dutch GPs from University Departments of
General Practice participated in four separate focus groups. These
discussions were held between November 1998 and March 1999. Each
discussion was tape-recorded and transcribed verbatim. From this
transcription, key factors and issues were identified. GPs reported that
they do not generally take out-of-pocket costs into account. Fully
reimbursed drugs were usually prescribed and GPs felt that most patients
were highly motivated and thus willing to pay for their medication. The
patient charges were seen to be low and not likely to affect patients'
willingness to pay. GPs felt that patients need not have to pay for
their medication. They adjusted their drug choice in order to avoid
co-payment and were willing to agree to a patient's demand for a
reimbursed prescription. GPs describe their prescribing as not
influenced by out-of-pocket costs. GPs seem inclined to avoid co-payment
for patients when patients have financial difficulties and the disease
is perceived as severe. They chose fully reimbursed drugs.
Publication Types:
MeSH Terms:
- Attitude of Health Personnel*
- Decision Making
- Deductibles and Coinsurance
- Drug Utilization/economics*
- Drug Utilization/statistics & numerical data
- Dyspepsia/drug therapy
- Family Practice
- Financing, Personal*
- Focus Groups
- Hay Fever/drug therapy
- Hormone Replacement Therapy/economics
- Hormone Replacement Therapy/utilization
- Human
- Hypertension/drug therapy
- Insurance, Pharmaceutical Services
- Netherlands
- Physician's Practice Patterns/economics*
- Physician's Practice Patterns/statistics & numerical data
- Physicians, Family/psychology*
- Prescription Fees*
- Qualitative Research
- Support, Non-U.S. Gov't
PMID: 12297243 [PubMed - indexed for MEDLINE]
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Patients' attitudes to medicines and expectations for
prescriptions.
Britten N, Ukoumunne OC, Boulton MG.
Department of General Practice and Primary Care, Guy's King's and St
Thomas' School of Medicine, King's College, London, UK. nicky.britten@kcl.ac.uk
BACKGROUND: Recent research has shown that patients' expectations for
prescriptions influence doctors' prescribing decisions, but little is
known of the antecedents of these expectations. OBJECTIVES: To test
earlier qualitative research about patients' views of medicines; to
describe the demographic characteristics of those holding orthodox and
unorthodox views of medicines; to investigate the relationship between
patients' ideal and predicted expectations for prescriptions; and to
determine the relative effects of attitudinal, demographic,
organizational and illness variables on these expectations. DESIGN:
Questionnaire survey of patients consulting general practitioners.
SETTING AND PARTICIPANTS: A total of 544 patients and 15 doctors in four
general practices. MAIN VARIABLES STUDIED: Patients' attitudes to
medicines; patients' demographic characteristics; organizational
variables; aspects of patients' presenting problems. OUTCOME MEASURES:
Patients' ideal and predicted expectations for prescriptions. RESULTS:
Orthodox and unorthodox attitudes to medicines can be measured
quantitatively, and ethnicity was the only demographic variable
associated with both. Ideal and predicted expectations for prescriptions
were closely related to each other but differed in their antecedents.
Both types of expectations were associated with attitudinal,
demographic, organizational and illness variables. Ideal expectations
were influenced by orthodox and unorthodox attitudes to medicines, while
predicted expectations were only influenced by orthodox attitudes.
CONCLUSIONS: Future studies of patients' expectations for health
services should distinguish between ideal and predicted expectations,
and should consider the range of possible influences on these
expectations. In particular, the effect of the organization and context
of health services should be investigated.
MeSH Terms:
- Adult
- Age Distribution
- Aged
- Attitude to Health*
- Drug Therapy/psychology*
- Family Practice*
- Female
- Health Status
- Human
- London
- Male
- Middle Age
- Questionnaires
- Regression Analysis
- Sex Distribution
- Support, Non-U.S. Gov't
PMID: 12199664 [PubMed - indexed for MEDLINE]
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Economic messages in prescription drug advertisements
in medical journals.
Neumann PJ, Zivin Bambauer K, Ramakrishnan V, Stewart KA, Bell CM.
Program on the Economic Evaluation of Medical Technology, Center for
Risk Analysis Harvard School of Public Health, Boston, Massachusetts
02115, USA. pneumann@hsph.harvard.edu
BACKGROUND: The extent to which pharmaceutical companies promote the
economic advantages of their products in advertisements in medical
journals, and whether such claims are supported by evidence, has not
been quantified. Our objectives were to examine how often prescription
drug advertisements in leading medical journals contain economic
messages, and to determine the types of promotional claims made and
whether supporting evidence is provided. METHODS: All prescription drug
advertisements appearing in six leading general medical and specialty
journals in 3 selected months annually from 1990 to 1999 were reviewed.
Using a standard data collection form, two reviewers examined each ad
for economic content-including mention of the drug's price, value, cost
saving, or cost-effectiveness. RESULTS: Economic messages appeared in
237 (11.1%) of the 2144 advertisements examined. Proportion of ads with
economic content has increased over time (P = 0.003). Most frequently,
economic ads contained statements that drugs were "less expensive" or
"cost less" than alternative treatments (50.6% of economic ads).
Supporting evidence for economic claims was clearly reported in 63.7% of
cases, and typically referred to published drug prices rather than more
detailed economic analysis. Ads for calcium channel blocking agents and
ACE inhibitors frequently contained economic messages. CONCLUSIONS:
Economic messages about prescription drugs are used in advertisements in
leading medical journals and their frequency may be rising. Physicians
should be aware of this phenomenon, and its potential impact on their
prescribing decisions. More scrutiny of the supporting evidence
underlying economic claims by the medical community and regulators may
be needed.
MeSH Terms:
- Advertising*
- Cost Savings
- Cost-Benefit Analysis
- Drug Industry
- Human
- Periodicals*
- Pharmaceutical Preparations/economics*
- Support, Non-U.S. Gov't
Substances:
- Pharmaceutical Preparations
PMID: 12218774 [PubMed - indexed for MEDLINE]
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The value of clinical judgement analysis for |
