This post is tangentially related to the back and forth I’m having with DB’s Medical Rants about evidence-based medicine. I owe DB a follow up to his post in which I will (hopefully) explain that capturing information about medical care and using it to improve said care is possible and will become more widespread. However, that post has to wait a day or so. In the meantime there are some interesting reports out that impact on how drugs get used and why practicing the best evidence-based medicine is so difficult (but not impossible!). This was, if you remember, my earlier notion before I got forced into defending the concept of EBM–a defense I will take up again very soon!
First, there’s been a new study out from Express Scripts the PBM which last month put out a study showing that patients were being prescribed Cox-2 inhibitors like Celebrex, even though they should have made do with NSAIDS or ibuprofen. In their latest study the same team at Express Scripts looked at the combined use of Cox-2 Inhibitors with PPIs (like Prilosec). The theory is that Cox-2 inhibitors are better for the GI tract than NSAIDs, so that people getting Cox-2’s should be using fewer PPIs than those getting simple NSAIDs. In fact the study found:
. . . .many COX-2 prescribing physicians actually continued co-prescribing gastroprotective drugs like proton pump inhibitors or H(2) receptor antagonists …..gastroprotective drug use was actually higher for COX-2 patients than for those taking a traditional NSAID – by a margin of 20% vs. 18%.
And that’s not quite all, another Express Scripts study from the team lead by Cox, too (sorry, but I had to get that in somewhere!), found that the use of PPIs to reduce death by ulcers was not in the least cost-effective.
In a September Journal of Managed Care Pharmacy article they reported that economic models used to compare ulcer treatments overstated the cost-effectiveness of more expensive treatments. They looked at treatments that combined antibiotics with either a generic bismuth drug or a more expensive branded proton pump inhibitor (PPI). The more economical bismuth-based treatment was actually the most cost-effective.
Forbes, a magazine which spends much of its time promoting the pharma industry, actually got so interested in this that they ran an article saying that it costs $150,000 To Prevent An Ulcer Death. Why is this happening? Well physicians prescribe based in part on detailing and patient demand driven by DTC and Internet advertising–to quote a recent survey-based study on the impact of the patient-physician relationship in the Internet age
Physicians appear to acquiesce to clinically-inappropriate requests generated by information from the Internet, either for fear of damaging the physician-patient relationship or because of the negative effect on time efficiency of not doing so.
So in this half of the equation we’ve got doctors prescribing drugs they shouldn’t really be prescribing for a variety of reasons that don’t have much to do with following the best evidence-based medicine. Meanwhile on the other side of the relationship there’s a new set of numbers out from Harris and BCG showing that, as we always knew, non-compliance in pharmaceutical regimens is rife. And it’s rife for a variety of reasons. Why didn’t patients take the pill the doctor prescribed?
20 percent of patients who forgo medications said they do so because they perceive a drug’s side effects to be undesirable or debilitating, 17 percent because they find the medicines too costly, and 14 percent because they don’t think they need the drug. This last group of patients view themselves, not their doctors, as the best ultimate judges of what medications they should take and when. Also among those actively not complying with doctors’ orders are the 10 percent of patients who said they find it difficult to get the written prescription to the pharmacy or to get the filled prescription home.
BCG’s spin on this is that it’s the patients’ fault. But why would you take a drug if you couldn’t afford it or if it made you sick, and why would you trust your doctor over yourself? So there’s a combination of factors here that require education, communication and financial support for patients as well as doctors.
So my conclusion is that as there’s still lots of work to do in figuring out how to do a seemingly simple thing like getting patients to take their pills. And there’s an equal amount of work in getting doctors to prescribe them the right pills. That’s if we can decide what the right pill is for the right patient, which as is common knowledge, we can’t.
Damn, I just realized that I forgot to take my one new and daily med yesterday!