Daniel Lessler

A physician survey of the effect of drug sample availability on physicians' behavior

AbstractOBJECTIVE: Pharmaceutical companies often use drug samples as a marketing strategy in the ambulatory care setting. Little is known about how the availability of drug samples affects physicians’ prescribing practices. Our goal was to assess: (1) under what circumstances and why physicians dispense drug samples, (2) if drug samples lead physicians to use medications other than their preferred drug choice, and (3) the physician characteristics that are associated with drug sample use. DESIGN: Cross-sectional survey. SETTING: University-based clinics at one academic medical center. PARTICIPANTS: 154 general medicine and family physicians. MEASUREMENTS AND MAIN RESULTS: Physicians’ self-reported prescribing patterns for 3 clinical scenarios, including their preferred drug choice, whether they would use a drug sample and subsequently prescribe the sampled medication, and the importance of factors involved in the decision to dispense a drug sample. A total of 131 (85%) of 154 physicians responded. When presented with an insured woman with an uncomplicated lower urinary tract infection, 22 (17%) respondents reported that they would dispense a drug sample; 21 (95%) of 22 sample users stated that they would dispense a drug sample that differed from their preferred drug choice. For an uninsured man with hypertension, 35 (27%) respondents reported that they would dispense a drug sample; 32 (91%) of 35 sample users indicated that they would dispense a drug sample instead of their preferred drug choice. For an uninsured woman with depression, 108 (82%) respondents reported that they would dispense a drug sample; 53 (49%) of 108 sample users indicated that they would dispense a drug sample that differed from their preferred drug choice. Avoiding cost to the patient was the most consistent motivator for dispensing a drug sample for all 3 scenarios. For 2 scenarios, residents were more likely to report using drug samples than attendings (P<.05). When respondents who chose a drug sample for 2 or 3 scenarios were compared to those who never chose to use a drug sample, or chose a drug sample for only one scenario, only younger age was independently associated with drug sample use. CONCLUSION: In self-reports, the availability of drug samples led physicians to dispense and subsequently prescribe drugs that differ from their preferred drug choice. Physicians most often report using drug samples to avoid cost to the patient.

DO TREATMENT RESTRICTIONS IMPOSED BY UTILIZATION MANAGEMENT INCREASE THE LIKELIHOOD OF READMISSION FOR PSYCHIATRIC PATIENTS

OBJECTIVES The use of utilization management as a cost-containment strategy has led to debate and controversy within the field of mental health. Little is currently known about how this cost-containment approach affects patient care or quality. The aim of this investigation was to determine whether treatment restrictions imposed on privately insured psychiatric patients by a utilization management program affected the likelihood of readmission. METHODS The utilization management program included three review activities: preadmission certification, concurrent review, and case management. During a 5-year period (1989-1993), 3,073 inpatient reviews were performed on 2,443 privately insured psychiatric patients. Using logistic regression, restrictions imposed by utilization management on length-of-stay in relation to 60-day readmission rates were investigated. RESULTS The most common diagnoses among the psychiatric patients whose care was reviewed were alcohol dependence (22.9%), recurrent depression (22.5%), and single-event depression (20.8%). On average, 22.4 days of inpatient psychiatric treatment was requested through the review procedures, and 15.5 days of care were approved by the utilization management program. Of the 2,443 patients reviewed, 7.9% had a readmission within 60 days of their initial admission. Patients whose length-of-stay was restricted by utilization management were more likely to be readmitted. For each day that the requested length-of-stay was reduced, the adjusted odds of readmission within 60 days increased by 3.1% (P = 0.004). CONCLUSIONS The utilization management program restricted access to inpatient psychiatric care by limiting length of stay. Although this approach may promote cost containment, it also appears to increase the risk of early readmission. Continuing attention should be paid to investigating the effects on quality of utilization management programs aimed at containing mental health costs.

Junior faculty's perspectives on mentoring.

The prevalence and characteristics of mentorship among junior faculty in clinician–scientist and clinician–educator tracks were evaluated. Comprehensive improvement strategies are needed.

A clinic-based mammography intervention targeting inner-city women.

ObjectiveThe objective was to evaluate the effect of a clinic-based intervention program on mammography use by inner-city women.DesignA randomized controlled trial employing firm system methodology was conducted.SettingThe study setting was a general internal medicine clinic in the university-affiliated county hospital serving metropolitan Seattle.ParticipantsWomen aged 50 to 74 years with at least one routine clinic appointment (when they were due for mammography) during the study period were enrolled in the trial (n=314).InterventionsThe intervention program emphasized nursing involvement and included physician education, provider prompts, use of audiovisual an printed patient education materials, transportation assistance in the form of bus passes, preppointment telephone or postcard reminders, and rescheduling assistance. Control firm women received usual care.Measurement and Main ResultsMammography completion within 8 weeks of clinic visits was significantly higher among intervention (49%) than control (22%) firm women (p<.001). These effects persisted after adjustment for potential confounding by age, race, medical insurance coverage, and previous mammography experience at the hospital (odds ratio 3.5; 95% confidence interval 1.9, 6.5). The intervention effect was modified by type of insurance coverage as well as prior mammography history. Process evaluation indicated that bus passes and rescheduling efforts did not contribute to the observed increases in screening participation.ConclusionsA clinic-based program incorporating physician education, provider prompts, patient education materials, and appointment reminders and emphasizing nursing involvement can facilitate adherence to breast cancer screening guidelines among inner-city women.

EFFECTS OF UTILIZATION MANAGEMENT ON PATTERNS OF HOSPITAL CARE AMONG PRIVATELY INSURED ADULT PATIENTS

OBJECTIVES This study examined the effects of utilization management review activities on patterns of hospital care among a sample of adult patients insured through a managed fee-for-service plan. METHODS The study was a retrospective analysis of insurance administrative data representing a case series of patients for whom utilization management review was performed. Two review activities were analyzed: pre-admission review and concurrent (continued stay) review. Patients were 49,654 privately insured adult patients reviewed for care between January 1989 and December 1993. Review outcomes included inpatient or outpatient care denied, site of treatment shifted (from inpatient to outpatient), or reduction in requested hospital days (total days requested - total days approved). RESULTS Few patients (<1%) were denied care at time of admission or were required to obtain outpatient instead of inpatient care. More common was action taken to limit length of stay by concurrent review, which accounted for 83% of the total reduction (25,197 requested days) in inpatient care. Utilization management became more restrictive with time: the number of days approved declined by 15% to 50% from 1990 to 1993, depending on the type of admission. Utilization management was most forceful in restricting care for mental health patients, who represented 5.7% of the study population but accounted for 54.7% of the total reduction in requested days. CONCLUSIONS The utilization management program appeared to limit hospital care by managing length of stay once patients were admitted. The effects of restricting length of stay in this manner on quality and health outcomes should be investigated.

Glycemic and Lipid Control among Patients with Diabetes at Six U.S. Public Hospitals

Objective. Public hospital systems share a mission to provide access to healthcare regardless of ability to pay. While public hospital systems care for large numbers of socioeconomically vulnerable and ethnically diverse populations who have diabetes, little is known about the quality of diabetes care provided in these sites. Methods. We assessed the measurement and control of hemoglobin A1c (HbA1c) and lipids (LDL) in a sample of patients with diabetes with ≥2 outpatient visits per year in two consecutive years at one of 6 public hospitals (N=14,222). Results. High proportions of patients had at least one HbA1c and LDL measurement within 2 years (89% and 88%, respectively). Thirty-five percent had HbA1c<7.0%; 21% had HbA1c≥9.5%; 36% had LDL<100 mg/dl; 10% had LDL>160 mg/dl. Non-White patients and patients who were never insured were most at risk for poor glycemic and lipid control. Conclusions. The quality of care, as measured by glycemic and lipid monitoring and control among ongoing users of public hospital systems, was similar to that of other health systems, but disparities exist across race/ethnicity and insurance status. Because of the critical role these institutions play in providing care to the underserved, research is needed to explore factors contributing to differences in glycemic and lipid control and develop strategies to improve chronic disease management in these systems.

Self-Management Support in a Web-Based Medical Record: A Pilot Randomized Controlled Trial

Physicians were much less likely than other primary care team members to use a Web-based application to counsel patients with diabetes about behavior change.