Primary care physicians and the cost of drugs: a study of prescribing practices based on recognition and information sources

No longer a blank cheque: a narrative scoping review of physician awareness of cost

OBJECTIVES

Healthcare costs have been steadily rising, and attention to cost containment in healthcare systems is increasingly important. It has been previously established that physicians lack adequate awareness of cost in health care and that by increasing awareness, costs can be reduced. This scoping review examines cost awareness of medications, investigations and procedures and identifies potential interventions that may serve to improve physician awareness.

STUDY DESIGN

A scoping review was performed to evaluate the literature based on established Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.

METHODS

A review of electronic databases was performed for studies regarding physician awareness of cost, including PubMed, Embase, Cochrane Central Register of Controlled Trials and Google Scholar.

RESULTS

An initial 4350 citations were identified, and 76 articles were included for full text analysis. Combined, these studies assessed 18,901 physicians. The overwhelming majority (91%) found cost awareness in physicians was low and demonstrated significant room for cost reduction. Eighteen of the 76 studies assessed an intervention to improve physician awareness of cost and used either a price list (89%) or a teaching session (11%) as the primary intervention.

CONCLUSIONS

Research demonstrates that there is still a lack of awareness among physicians of the costs of medications, investigations and procedures/consumables. Initial approaches using price display and teaching sessions have shown promise. Further research into best practices for education around cost, beginning in medical school and continuing into established medical and surgical practices, may lead to increased cost savings in health care.

Cost-consciousness among Iranian internal medicine residents

Background: Study aimed at assessing residents' cost awareness and their attitude about health care costs.Methods: Internal medicine residents at teaching hospitals of Tehran University of Medical Sciences were surveyed during August-December 2016 using a researcher-made questionnaire comprising attitude statements and cost estimation of diagnostic and treatment items.Results: Eighty-nine residents completed the survey (response rate = 56.6%). The results indicate that less than one quarter (23.69%) of cost estimates were in the range of correct answers. The mean (SD) for correct estimation of medications (out of 8 scores), lab tests (out of 20 scores), and total (out of 35 scores) were 1.25 (0.96), 4.92 (0.27), and 7.97 (0.34), respectively. An analysis of variance showed that the level of residency was positively correlated with residents' correct cost estimation (F (3, 77)=9.98, p = 0.029). There was a significant positive correlation between age of residents with the correct estimate of medication prices (p = 0.018, r = 0.261).Conclusions: The internal medicine residents of Tehran University of Medical Sciences have poor knowledge of health care costs, including medications, diagnostic tests, and hospitalization costs. The results of this study explain the necessity of developing a training program for the transfer of cost information to physicians.

Information system technologies' role in augmenting dermatologists' knowledge of prescription medication costs

OBJECTIVES

Despite the recent rising costs of once affordable dermatologic prescription medications, a survey measuring dermatologists' attitudes, beliefs, and knowledge of the cost of drugs they commonly prescribe has not been conducted. Awareness of drug costs is hindered by a lack of access to data about the prices of medicines. No surveys of physicians have addressed this issue by proposing new information system technologies that augment prescription medication price transparency and measuring how receptive physicians are to using these novel solutions in their daily clinical practice. Our research aims to investigate these topics with a survey of physicians in dermatology.

METHODS

Members of the North Carolina Dermatology Association were contacted through their electronic mailing list and asked to take an online survey. The survey asked several questions about dermatologists' attitudes and beliefs about drug costs. To measure their knowledge of prescription medications, the National Average Drug Acquisition Cost was used as an authoritative price that was compared to the survey takers' price estimates of drugs commonly used in dermatology. Physicians' willingness to use four distinct information system technologies that increase drug price transparency was also assessed.

RESULTS

Dermatologists believe drug costs are an important factor in patient care and believe access to price information would allow them to provide a higher quality of care. Dermatologists' knowledge of the costs of medicines they commonly prescribe is poor, but they want to utilize information system technologies that increase access to drug pricing information.

CONCLUSIONS

There is an unmet demand for information system technologies which increase price transparency of medications in dermatology. Physicians and IT professionals have the opportunity to create novel information systems that can be utilized to help guide cost conscious clinical decision making.

Physician awareness of drug cost: a systematic review

BACKGROUND

Pharmaceutical costs are the fastest-growing health-care expense in most developed countries. Higher drug costs have been shown to negatively impact patient outcomes. Studies suggest that doctors have a poor understanding of pharmaceutical costs, but the data are variable and there is no consistent pattern in awareness. We designed this systematic review to investigate doctors' knowledge of the relative and absolute costs of medications and to determine the factors that influence awareness.

METHODS AND FINDINGS

Our search strategy included The Cochrane Library, EconoLit, EMBASE, and MEDLINE as well as reference lists and contact with authors who had published two or more articles on the topic or who had published within 10 y of the commencement of our review. Studies were included if: either doctors, trainees (interns or residents), or medical students were surveyed; there were more than ten survey respondents; cost of pharmaceuticals was estimated; results were expressed quantitatively; there was a clear description of how authors defined "accurate estimates"; and there was a description of how the true cost was determined. Two authors reviewed each article for eligibility and extracted data independently. Cost accuracy outcomes were summarized, but data were not combined in meta-analysis because of extensive heterogeneity. Qualitative data related to physicians and drug costs were also extracted. The final analysis included 24 articles. Cost accuracy was low; 31% of estimates were within 20% or 25% of the true cost, and fewer than 50% were accurate by any definition of cost accuracy. Methodological weaknesses were common, and studies of low methodological quality showed better cost awareness. The most important factor influencing the pattern and accuracy of estimation was the true cost of therapy. High-cost drugs were estimated more accurately than inexpensive ones (74% versus 31%, Chi-square p < 0.001). Doctors consistently overestimated the cost of inexpensive products and underestimated the cost of expensive ones (binomial test, 89/101, p < 0.001). When asked, doctors indicated that they want cost information and feel it would improve their prescribing but that it is not accessible.

CONCLUSIONS

Doctors' ignorance of costs, combined with their tendency to underestimate the price of expensive drugs and overestimate the price of inexpensive ones, demonstrate a lack of appreciation of the large difference in cost between inexpensive and expensive drugs. This discrepancy in turn could have profound implications for overall drug expenditures. Much more focus is required in the education of physicians about costs and the access to cost information. Future research should focus on the accessibility and reliability of medical cost information and whether the provision of this information is used by doctors and makes a difference to physician prescribing. Additionally, future work should strive for higher methodological standards to avoid the biases we found in the current literature, including attention to the method of assessing accuracy that allows larger absolute estimation ranges for expensive drugs.

PA attitudes toward prescription drug costs

PURPOSE

This descriptive comparative study assessed PAs' knowledge of drug costs and attitudes about prescribing prescription medications.

METHOD

Data were collected using a modified questionnaire. The survey instrument assessed PAs' attitudes about prescribing as well as their knowledge of prescription medication costs.

RESULTS

Forty percent of the sample population were able to accurately identify the correct cost of medications. Most of the sample population considered costs when making a prescriptive decision. There were significant differences in the prescribing attitudes of PAs in various practice settings and medical specialties.

CONCLUSIONS

The results of this study with PAs are similar to those of previous investigations involving physicians' knowledge of drug costs. We should recognize this deficit and ensure that a discussion of drug costs, particularly those associated with the Medicare population, is an important part of PA continuing education.

Health professionals: how do they assess new medicines?

OBJECTIVE

To identify the types of information used by health professionals when assessing a new medicine, and to discover whether measures of clinical effectiveness and cost-effectiveness are understood and used.

METHOD

A cross-sectional survey of 56 health professionals was undertaken in a tertiary hospital in New Zealand. Respondents were consultants, registrars, house-surgeons, pharmacists, and specialist nurses

MAIN OUTCOME MEASURES

Health professionals' opinions on clinical and cost information required for assessing a new medicine; their ability to calculate measures of risk; and their ability to define clinical effectiveness, cost-effectiveness and types of economic analysis.

RESULTS

Thirty-four percent of respondents considered journals and research to be the most accurate sources of information when assessing a new medicine. Efficacy, safety, contraindications and side-effects were the most important information sought. In total, 93% gave an acceptable definition of clinical effectiveness, and 38% of cost-effectiveness. The majority of each profession (except specialist nurses) could calculate relative risk reduction (RRR) and absolute risk reduction (ARR) but fewer could calculate numbers needed to treat (NNT). Eighty-four percent of respondents felt that cost affected their assessment of a new medicine. Less than a quarter of respondents could define each type of economic analysis. Consultants and pharmacists appeared to have the best knowledge of economic analysis.

CONCLUSION

Efficacy, safety, contraindications and side-effects were the most important information sought when assessing a new medicine. Health professionals' knowledge of clinical effectiveness was greater than their knowledge of cost-effectiveness. Consultants and pharmacists appeared to have the best knowledge of economic analysis.

The Use of Antibiotics for Viral Upper Respiratory Tract Infections: An Analysis of Nurse Practitioner and Physician Prescribing Practices in Ambulatory Care, 1997-2001

PURPOSE

There are extensive data that describe the prescriptive behaviors of physicians (MDs) for upper respiratory tract infections; however, there is a paucity of data on the antibiotic-prescribing patterns of nurse practitioners (NPs). The purpose of this study was to describe and predict factors that are associated with antibiotic prescribing by NPs and MDs for viral upper respiratory infections in the ambulatory setting.

DATA SOURCES

The study utilized a cross-sectional retrospective design of data from the National Hospital Ambulatory Medical Care Survey and the National Ambulatory Medical Care Survey between 1997 and 2001. Data were collected on a national probability sample of 506 NP and 13,692 MD visits for patients with nonspecific upper respiratory tract infection, viral pharyngitis, and bronchitis.

CONCLUSIONS

Bivariate analysis found no significant differences in antibiotic prescribing for viral upper respiratory tract infections by NPs (50.4%) and MDs (53%). Broad-spectrum antibiotics accounted for 36.6% of the NP antibiotic prescriptions and for 33.2% of the MD antibiotic prescriptions. Multivariate analysis identified several clinical and nonclinical factors that are associated with NP antibiotic prescribing. The strongest positive predictors of NP antibiotic prescribing were black race, Medicaid insurance, Northeast region, and diagnoses of viral pharyngitis and bronchitis. The significant negative predictor was Medicaid insurance status. The strongest positive predictors of MD prescribing were viral pharyngitis, bronchitis, and non-antibiotic prescription.

IMPLICATION FOR PRACTICE

The excessive use of antibiotics for upper respiratory infections of viral etiology by both NPs and MDs suggests the continuing need for educational initiatives such as "academic detailing" as well as increasing involvement by both groups of providers in the dissemination of clinical guidelines and system-based quality assurance programs. Also, the lower rate of antibiotic prescribing for viral infections by NPs for patients with Medicaid insurance suggests more appropriate cost-effective care in this population of patients. More study is needed in general on prescribing by NPs for Medicaid patients. Finally, the strong association of nonclinical factors suggests the need for awareness and improvement of prescribing decisions by both NPs and MDs.

A qualitative study of GPs’ and PCO stakeholders’ views on the importance and influence of cost on prescribing

With prescribing expenditure rising and evidence of prescribing costs variation, general practitioners (GPs) in the UK are under increasing pressure to contain spending. The introduction of cash-limited, unified budgets and increased monitoring of prescribing within Primary Care Organizations (PCO) are intended to increase efficiency and enhance GPs financial responsibility. Whilst GPs regularly receive data on the costs of their prescribing and also performance against a set prescribing budget, little is known about the extent to which GPs take cost into account in their prescribing decisions. This study undertook a qualitative exploration of the attitudes of various stakeholders on the relative importance and influence of cost on general practice prescribing. In order to explore a plurality of perspectives, data were obtained from focus groups and a series of individual semi-structured interviews with GPs and key PCO stakeholders. The data suggest that although almost all GPs believed costs should be taken into account when prescribing, there was great variation in the extent to which this was applied and to how sensitive GPs were to costs. Cost was secondary to clinical effectiveness and safety, whilst individual patient need was emphasized above other forms of rationality or notions of opportunity costs. Conflict was apparent between a PCO policy of cost-containment and GPs' resistance to cost-cutting. GPs largely applied simple cost-minimization while cost-consideration was undermined by contextual factors. Implications for research and policy are discussed.

Communication of Drug Affordability between Physicians and Elderly Patients

Objective:

To identify characteristics among elderly patients associated with patient–provider communications regarding affordability of medications in prescribing and dispensing.

Methods:

Telephone survey data from consumers ≥65 years old collected in the Texas Tech 5000 Survey were used. The sample size for the analyses was 2,360. Demographics, insurance, financial factors, nonfinancial factors, prescription drug use, and health status were used to identify which subgroup of elderly patients recalled communication with their providers regarding the affordability of prescriptions. Statistical analyses included bivariate analyses and a multivariate logistic regression.

Results:

Eleven percent of the respondents reported being asked by their physicians whether they could afford prescription drugs. In the multivariate analysis, gender, race, insurance coverage for prescriptions, income, number of physician visits, out-of-pocket expenditure for prescriptions, health, and physicians' participatory decision-making score were found to be associated with patient–provider communications regarding affordability of medications.

Conclusions:

Further research needs to be conducted to identify ways to improve patient–provider relationships to facilitate communication regarding affordability of medications among elderly patients. Improved communication or sensitivity to prescription affordability has the potential to increase patient medication adherence and improve clinical outcomes.

Awareness of the side effects of possessed medications in a community setting

OBJECTIVE

To evaluate in a community setting the extent of and parameters related with awareness of side effects of medications by health consumers.

METHODS

We performed in-house interviews in an entire community. The population of the community of Chalki, Greece, was surveyed. Detailed information was recorded on all medications possessed by each individual. The main outcome measure was awareness of medication side effects.

RESULTS

A total of 1079 medications were recorded among 279 subjects. Among 180 subjects for whom direct information was available, and who possessed at least one medication only 47 (26%) were aware of the side effects of at least one of their medications. Side effects awareness was more frequent in subjects who had experienced some adverse event themselves (76%), in those with completed university education (67%), ex-smokers (46%), housewives (45%), and never married adults (41%) and was less frequent in more permanent island residents (odds ratio 0.76 per 10% of lifetime spent in the island) and economic immigrants (0%). Side effects awareness existed for only 8% of the possessed medications and was more frequent when an adverse event had been experienced (54%), for medications not provided locally initially (28%), and for medications for joint and musculoskeletal problems (15%). Awareness rates were unrelated to availability of prescription, specialist involvement, or follow-up by a physician concerning the specific medication.

CONCLUSIONS

Awareness of side effects was infrequent in this community setting and was determined mostly by live experiences of adverse events and social parameters. There is a need to improve the dissemination of adequate safety information among consumers in the ambulatory use of pharmaceuticals.

Improving physicians' knowledge of the costs of common medications and willingness to consider costs when prescribing

OBJECTIVES

To determine the effectiveness of an educational intervention designed to improve physicians' knowledge of drug costs and foster willingness to consider costs when prescribing.

DESIGN

Pre- and post-intervention evaluation, using physicians as their own controls.

SETTING

Four teaching hospitals, affiliated with 2 residency programs, in New York City and northern New Jersey.

PARTICIPANTS

One hundred forty-six internal medicine house officers and attendings evaluated the intervention (71% response rate). Of these, 109 had also participated in a pre-intervention survey.

INTERVENTION

An interactive teaching conference and distribution of a pocket guide, which listed the average wholesale prices of over 100 medications commonly used in primary care

MEASUREMENTS AND MAIN RESULTS

We administered a written survey, before and 6 months after the intervention. Changes in attitudes and knowledge were assessed, using physicians as their own controls, with Wilcoxon matched-pairs signed-rank tests. Eighty-five percent of respondents reported receiving the pocket guide and 46% reported attending 1 of the teaching conferences. Of those who received the pocket guide, nearly two thirds (62%) reported using it once a month or more, and more than half (54%) rated it as moderately or very useful. Compared to their baseline responses, physicians after the intervention were more likely to ask patients about their out-of-pocket drug costs (22% before vs 27% after; P <.01) and less likely to feel unaware of drug costs (78% before vs 72% after; P =.02). After the intervention, physicians also reported more concern about the cost of drugs when prescribing for patients with Medicare (58% before vs 72% after; P <.01) or no insurance (90% before vs 98% after; P <.01). Knowledge of the costs of 33 drugs was more accurate after the intervention than before (P <.05).

CONCLUSION

Our brief educational intervention led to modest improvements in physicians' knowledge of medication costs and their willingness to consider costs when prescribing. Future research could incorporate more high-intensity strategies, such as outreach visits, and target specific prescribing behaviors.

Knowledge of Hospital Acquisition Costs of Antibiotics among Physicians in a Community Hospital

Purpose

Cost-conscious prescribing requires that physicians be knowledgeable about drug costs. A cost card was used as the primary method of educating physicians about antibiotic costs in this facility. A survey was conducted to determine physicians' knowledge of the acquisition costs of antibiotics and to assess the effectiveness of the cost card as an educational tool.

Methods

Surveys were sent to 433 physicians in the departments of medicine and surgery. Physicians were asked to designate a hospital cost range for 25 antibiotics on formulary. Percentages of correct responses were determined for all antibiotics. Physicians were also asked a series of questions about their sources of drug cost information and whether they believed that this information was sufficient.

Results

The average percentage of correct answers to the antibiotic cost questions was 31.7%. Of physicians surveyed, 53% felt that they did not receive enough information regarding drug costs and 57% felt that it would be helpful to have more frequent cost updates.

Conclusions

Despite efforts to provide antibiotic cost information via a cost card, physicians for the most part are not cognizant of antibiotic costs. Physicians are aware that they lack knowledge about the cost of these drugs and desire further information and education. Educational initiatives will be implemented to facilitate cost-conscious prescribing.

[Explanatory variables of avoidable cost produced by not prescribing a cheaper equivalent drug]

OBJECTIVE

To identify the explanatory variables of avoidable cost produced by not prescribing a cheaper equivalent drug.

METHODS

We conducted a cross-sectional study of 1,500 primary care physicians in Galicia (northwest Spain). The sample consisted of 405 primary care physicians. The following independent variables were collected through a postal questionnaire physicians' training and specialty, physicians' perception of the quality of available drug information sources, type of practice, and number of patients. The environmental characteristics of the practice were obtained from secondary sources. Multiple regression models were constructed using as dependent variables two indicators based on unnecessary cost produced by not prescribing cheaper equivalents.

RESULTS

The response rate was 77,4%. No association was found between prescription efficiency and the level of the physician's training, or with the variables of utilization or the quality of commercial and institutional information. The variable of health model was not significant. The only statistically significant variables were the number of identification cards and the percentage of pensioners' identification cards.

CONCLUSIONS

The results of this study suggest that physicians attach little importance to prescription efficiency. Thus, to decrease avoidable cost produced by not prescribing a cheaper equivalent drug, the medical curriculum should be modified to ensure that is contents reflect national health priorities and current resources.

Psychiatrists' knowledge and attitudes about costs of commonly prescribed treatments in psychiatry

A survey was conducted to assess psychiatrists' knowledge and attitudes regarding the costs of various psychiatric treatments. Psychiatrists (n = 500) were randomly selected from the membership of the Ohio Psychiatric Association. The survey explored several aspects of psychiatrists' knowledge of costs, including estimated prices of 24 specific psychiatric treatments (frequently used psychotropic medications, laboratory tests, and inpatient and outpatient procedures) as well as their level of confidence in their estimates. The survey also asked a series of attitude/opinion questions and specific demographic data. The psychiatrists (n = 265, 59% response) perceived that knowing the costs of treatments was an important consideration when choosing a particular treatment. Psychiatrists' actual knowledge of the costs of treatment was inconsistent with their beliefs of the importance of knowing the costs as well as their reported confidence in their knowledge of costs. Information about the costs of psychiatric treatments is an important clinical consideration and a program to improve clinicians' knowledge of the costs of psychiatric treatment could occur during residency training.

Monetary and nonmonetary costs to patients attending an ambulatory dermatology clinic

BACKGROUND

Despite universal coverage under a provincial health plan, the residents of Ontario, Canada, still bear some costs for outpatient care, particularly for prescription drugs.

OBJECTIVE

To determine the financial and nonmonetary costs borne by patients presenting at a dermatology clinic in an academic centre, and to assess the extent to which these costs were problematic.

METHODS

Consecutive new patients in a 6-week period completed a self-administered questionnaire.

RESULTS

Eighty-six of 140 questionnaires (61%) were returned for analysis. The mean total cost to patients was C$28.92 (range $0 to $177.00). Medications were the largest expense (mean $35.66 for those receiving medication). Despite relatively prompt referrals (mean 12.4 days) and short in-office waiting time (mean 26.5 minutes), there was a trend for subjects to rate time costs as more problematic than monetary costs.

CONCLUSION

Patients attending a dermatology clinic bear variable monetary and nonmonetary costs. For some patients these costs may have the potential to impair access to care.