Drug expectations and drug choices of hospital physicians

Norwegian physicians' knowledge of the prices of pharmaceuticals: a survey

The objectives of this study are to measure physicians’ knowledge of the prices of pharmaceuticals, and investigate whether there are differences in knowledge of prices between groups of physicians. This article reports on a survey study of physicians’ knowledge of the prices of pharmaceuticals conducted on a representative sample of Norwegian physicians in the autumn of 2010. The importance of physicians’ knowledge of costs derives from their influence on total spending and allocation of limited health-care resources. Physicians are important drivers in the effort to contain costs in health care, but only if they have the knowledge needed to choose the most cost-effective treatment options. A survey was sent to 1 543 Norwegian physicians, asking them for price estimates and their opinions on the importance of considering the cost of treatment to society as a decision factor when treating their patients. This article deals with a subsection in which the physicians were asked to estimate the price of five pharmaceuticals: simvastatin, alendronate (Fosamax), infliximab (Remicade), natalizumab (Tysabri) and escitalopram (Cipralex). The response rate was 65%. For all the five pharmaceuticals, more than 50% and as many as 83% gave responses that differed more than 50% from the actual drug price. The price of more expensive pharmaceuticals was underestimated, while the opposite was the case for less expensive medicines. The data show that physicians in general have poor knowledge of the prices of the pharmaceuticals they offer their patients. However, the physicians who frequently deal with a drug have better knowledge of its price than those who do not handle a medication as often. The data also suggest that those physicians who agree that cost of care to society is an important decision factor have better knowledge of drug prices.

Therapeutic reasoning: from hiatus to hypothetical model

Rationale Extensive research has been conducted on clinical reasoning to gain better understanding of this process. Clinical reasoning has been defined as the process of thinking critically about the diagnosis and patient management. However, most research has focused on the process of diagnostic reasoning. Because of the lack of understanding regarding therapeutic reasoning, education in patient management decisions lacks a solid theoretical basis. Aims and objective To improve medical education, training and refresher courses with regard to therapeutic decision making. Methods A search on the literature about clinical reasoning has been conducted. Based on this literature a hypothetical model of therapeutic reasoning is developed. Results It is assumed on the literature about diagnostic and therapeutic reasoning that after the diagnosis has been formulated, the process of determining the therapy is initiated by a concept called the therapy script. Patient cases unconsciously elicit such scripts and they consist of relevant treatments, knowledge and clinical experiences. Analytical and non-analytical processes determine the final choice of therapy. Subsequently, these processes adapt the therapy script continuously. Conclusions A hypothetical model of therapeutic reasoning has been developed in order to improve medical education, training and refresher courses with regard to therapeutic decision making. Future research should empirically test the validity of this hypothetical model in different phases of the medical education continuum.

Do medical students copy the drug treatment choices of their teachers or do they think for themselves?

Purpose

Although the importance of rational prescribing is generally accepted, the teaching of pharmacotherapy to undergraduate medical students is still unsatisfactory. Because clinical teachers are an important role model for medical students, it is of interest to know whether this extends to therapeutic decision-making. The aim of this study was to find out which factors contribute to the drug choices made by medical students and their teachers (general practitioners and clinical specialists).

Methods

Final-year medical students (n = 32), and general practitioners (n = 29), lung specialists (n = 26), orthopaedic surgeons (n = 24), and internists (n = 24) serving as medical teachers from all eight medical schools in the Netherlands participated in the study. They were asked to prescribe treatment (drug or otherwise) for uncomplicated (A) and complicated (B) written patient cases and to indicate which factors influenced their choice of treatment, using a list of factors reported in the literature to influence drug prescribing.

Results

Final-year medical students primarily based their drug choice on the factors ‘effectiveness of the drugs’ and ‘examples from medical teachers’. In contrast, clinical teachers primarily based their drug choice on the factors ‘clinical experience’, ‘effectiveness of the drugs’, ‘side effects of the drugs’, ‘standard treatment guidelines’, and ‘scientific literature’.

Conclusions

Medical teachers would appear to base their drug choice mainly on clinical experience and drug-related factors, whereas final-year medical students base their drug choice mainly on examples provided by their medical teachers. It is essential that medical teachers clearly explain to their students how they arrive at a specific choice of medication since medical students tend to copy the therapeutic drug choices from their teachers, mainly because of a lack of experience. Presenting students with clinical therapeutic problems early during undergraduate training will not only give them a chance to gain experience in solving medical problems but will also give meaning to what they are studying as opposed to merely reproducing what they learn or copying what they are told.

Price elasticity and pharmaceutical selection: the influence of managed care

State Medicaid programs are turning increasingly to managed care to control expenditures, although the types of managed care programs in use have changed dramatically. Little is known about the influence of the shifting Medicaid managed care arena on treatment decisions. This paper investigates factors affecting the selection of treatments for depression by providers participating in either of two Medicaid managed care programs. Of particular interest is the influence of medication price on the choice of treatment, since one vehicle through which managed care organizations can reduce total expenditures is by increasing the price sensitivity of participating providers. We take a new approach by phrasing the problem as a discrete choice, using a nested multinomial logit model for the analyses. Contrary to earlier literature, we find some evidence that physicians in both programs do take price into consideration when selecting among treatment options. HMO providers in particular demonstrate increased price sensitivity in the two most commonly prescribed categories of antidepressants.

The application of adverse drug reaction data to drug choice decisions made by pharmacy and therapeutics committees. An Australian perspective

Pharmacy and Therapeutics (P&T) committees undertake policy, regulatory and educational activities to promote rational use of medicines in their institutions with the aim of improving the quality of health and economic outcomes at these institutions. Formulary management is an important part of the P&T committees' activities and making drug choices is one of the committees' most difficult tasks. The 3 types of information most commonly identified by P&T committees as necessary for making drug choices are effectiveness, safety and cost data; usually in this order of importance. There is some evidence, however, that safety data are not considered by all committees when they make decisions about adding a new drug to a formulary. The role of adverse drug reaction (ADR) data in formulary decision-making (for registered drugs) occurs at several levels. First, ADR data obtained from pre-marketing studies of the drug are important and enable the committee to make an assessment of the risk of toxicity that should be anticipated for the drug. However, the limited nature of this information makes an absolute assessment impossible. Secondly, comparative safety information is necessary when deciding the place in therapy of a particular drug. Weighing up the comparative risks and benefits is a complex task which is a routine activity for most P&T committees whatever level of sophistication is applied. Thirdly, ADR data are an important ingredient of any economic assessment considered by a P&T committee. Calculation of the costs and consequences associated with the adverse effects of treatment demand careful assessment. Finally, aggregated adverse drug event reports which collate not only the consequences of adverse drug reactions but also medication incidents (medication errors) and which have been reported locally can be a useful quality assurance process for a P&T committee. This information will contribute to the identification of drugs for deletion from the formulary and less commonly in making decisions about additions to the formulary. As formulary management forms only part of a P&T committee's work, so the committee's interest in ADR is broader than the use of these data in making drug choices. The P&T committee may also be involved in promoting ADR reporting to either a central database or primary carers. Although often of limited availability, ADR information has an important role in the formulary management process of P&T committees.