David V. Evans

Effect of Drug Sample Removal on Prescribing in a Family Practice Clinic

PURPOSE Little is known about the impact of recent restrictions on pharmaceutical industry detailing and sampling on prescribing behavior, particularly within smaller, independent practices. The objective of this study was to evaluate the effect of a policy prohibiting prescription drug samples and pharmaceutical industry interaction on prescribing patterns in a rural family practice clinic in central Oregon. METHODS Segmented linear regression models were used to evaluate trends in prescribing using locally obtained pharmacy claims. Oregon Medicaid pharmacy claims were used to control for secular prescribing changes. Total and class-specific monthly trends in branded, promoted, and average prescription drug costs were analyzed 18 months before and after policy implementation. RESULTS Aggregate trends of brand name drug use did not change significantly after policy implementation. In aggregate, use of promoted agents decreased by 1.43% while nonpromoted branded agents increased by 3.04%. Branded drugs prescribed for respiratory disease declined significantly by 11.34% compared with a control group of prescribers. Relative to the control group, prescriptions of promoted cholesterol-lowering drugs and antidepressants were reduced by approximately 9.98% and 11.34%, respectively. The trend in average cost per prescription for lipid-lowering drugs was significantly reduced by

ANAL WARTS, SEXUALLY TRANSMITTED DISEASES, AND ANORECTAL CONDITIONS ASSOCIATED WITH HUMAN IMMUNODEFICIENCY VIRUS

0.70 per prescription per month. Overall, average prescription drug costs increased by

Breaking Up is Hard to Do: Lessons Learned from a Pharma-Free Practice Transformation

5.18 immediately after policy implementation. CONCLUSIONS Restriction of pharmaceutical industry representatives and samples from a rural family practice clinic produced modest reductions in branded drug use that varied by class. Although aggregate average costs increased, prescriptions for branded and promoted lipid-lowering agents and antidepressants were reduced.

The WWAMI Targeted Rural Underserved Track (TRUST) Program: An Innovative Response to Rural Physician Workforce Shortages.

Sexually transmitted diseases (STDs) are the cause of many different anorectal symptoms and complaints. Patients often present concerned that they have hemorrhoids. It is very important for primary care providers to be aware of the prevalance of anorectal STDs, common presentations, and management options. This article specifically addresses anal warts, gonorrhea, chlamydia, syphilis, herpes, and anorectal manifestations associated with HIV.

An Update on Inflammatory Bowel Disease

Background: Academic medical centers are examining relationships with the pharmaceutical industry and making changes to limit interactions. Most doctors, however, practice outside of academic institutions and see pharmaceutical detailers and accept drug samples and gifts. Little guidance for practicing physicians exists about transforming practices to become pharma-free. Consideration must be given to the impact on practice culture, staff views, and patient needs. Methods: A small private practice, setting out to transform into a pharma-free clinic, used a practice transformation process that examined the industry presence in the clinic, educated the doctors on potential conflicts of interest, and improved practice flow. Staff were given the opportunity to share concerns, and their issues were acknowledged. Educational interventions were developed to help providers keep current. Finally, efforts were made to educate patients about the policy. Results: The clinic recorded the degree to which it was detailed. Loss of gifts, keeping current with new drugs, and managing without samples were noted concerns. Policy change champions developed strategies to address concerns. Discussion: A shift in practice culture to a pharma-free clinic is achievable and maintainable over time. Barriers to success can be identified and overcome with attention given to careful gathering of information, staff input, and stakeholder education.

Capsule Commentary on Duru, et al., Potential Savings Associated with Drug Substitution in Medicare Part D: the Translating Research into Action for Diabetes (TRIAD) Study

PROBLEM Too few physicians practice in rural areas. To address the physician workforce needs of the Washington, Wyoming, Alaska, Montana, and Idaho (WWAMI) region, the University of Washington School of Medicine developed the Targeted Rural Underserved Track (TRUST) program in August 2008. TRUST is a four-year curriculum centered on a clinical longitudinal continuity experience with students repeatedly returning to a single site located in a rural community or small city. APPROACH The overarching theme of TRUST is one of linkages. Students are strategically linked to a rural community, known as their TRUST continuity community (TCC). The program begins with a targeted admission process and combines new and established programs and curricular elements to form a cohesive educational experience. This experience includes repeated preclinical visits, clerkships, and electives at a students TCC, and rural health courses, the Underserved Pathway, and the Rural Underserved Opportunities Program (which includes a community-oriented primary care scholarly project). OUTCOMES TRUST was piloted in Montana in 2008. With the matriculating class of 2015, every state in the WWAMI region will have TRUST students. From 2009 (the year targeted admissions began) to 2015, 123 students have been accepted into TRUST. Thirty-three students have graduated. Thirty (90.9%) of these graduates have entered residencies in needed regional specialties. NEXT STEPS Next steps include implementing a robust evaluation program, obtaining secure institutional programmatic funding, and further developing linkages with regional rural residency programs. TRUST may be a step forward in addressing regional needs and a reproducible model for other medical schools.

Outdoor-based leadership training and group development of family practice interns

Inflammatory bowel disease (IBD) includes 2 chronic idiopathic inflammatory diseases: ulcerative colitis and Crohn disease. The incidence and prevalence of IBD is increasing worldwide. It can affect people of all ages, including children and geriatric populations, and can impact all aspects of life. In this article, diagnosis and treatment of IBD in adults, pediatric, pregnant, and elderly populations are explored from the perspective of a primary care physician.

Pharmaceutical industry interactions in family medicine residencies decreased between 2008 and 2013: a CERA study.

The last several decades have seen advances in pharmaceutical technology. Diseases once untreated or only treated by surgery are now managed by medications. This advanced technology brings both increased numbers and costs of prescriptions. From 1999 to 2011, the number of prescriptions increased from 2.8 billion to 4 billion.1 In 2010, the U.S. spent 259 billion dollars on prescription medications, and this is projected to double by the end of this decade.2 What if there was a means of reducing the skyrocketing costs of prescription medications without limiting services or compromising care? In this study, Duru et al. examine therapeutic substitution as a means of doing just this.3 Common in many hospitals, therapeutic substitution is the use of an alternative medication that is not biologically equivalent, but has a similar effect as the original medication. Using a subset of 2007 Medicare part D data from a large national insurer, the authors identified the 50 highest costs drugs for the payor. The research team identified potential therapeutic substitutions for 27 to 30 of the 50 high cost drugs and calculated the potential cost savings to the patient, health plan and government. Their findings indicate a potential savings of 452 dollars per beneficiary—two to three times greater than that of generic substitution programs. There is general agreement that health care costs are too high and that the government needs to trim its expenditures. As the Affordable Care Act nears complete implementation and the number of insured increases, containment of prescription drug expenses will play an increasingly important role in controlling overall health care costs. This paper demonstrates a potential means of lowering pharmacy costs to patients, health plans and the government while still providing quality care. It is consistent with other ongoing efforts, including the National Physicians Alliance “Good Stewardship” program,4 that gave rise to the ABIM Foundation’s “Choosing Wisely” campaign.5 While further study to test multiple insurers and also the acceptability of therapeutic substitution to both patients and providers is needed, payers should take notice of this study as a potential method of cost savings.