OP-ED

Why You Should Care About the Drugs Your Doctor Prescribes

The following column appears today on THCB, in the op-ed pages of the Los Angeles Times and at ProPublica.

Your doctor hands you a prescription for a blood pressure drug. But is it the right one for you?

You’re searching for a new primary care physician or a specialist. Is there a way you can know whether the doctor is more partial to expensive, brand-name drugs than his peers?

Or say you’ve got to find a nursing home for a loved one. Wouldn’t you want to know if the staff doctor regularly prescribes drugs known to be risky for seniors or overuses psychiatric drugs to sedate residents?

For most of us, evaluating a doctor’s prescribing habits is just about impossible. Even doctors themselves have little way of knowing whether their drug choices fall in line with those of their peers.

Once they graduate from medical schools, physicians often have a tough time keeping up with the latest clinical trials and sorting through the hype on new drugs. Seldom are they monitored to see if they are prescribing appropriately — and there isn’t even universal agreement on what good prescribing is.

This dearth of knowledge and insight matters for both patients and doctors. Drugs are complicated. Most come with side effects and risk-benefit calculations. What may work for one person may be absolutely inappropriate, or even harmful, for someone else.

Antipsychotics, for example, are invaluable to treat severe psychiatric conditions. But they are too often used to sedate older patients suffering from dementia — despite a “black-box” warning accompanying the drugs that they increase the risk of death in such patients.

The American Geriatrics Society has labeled dozens of other drugs risky for elderly patients, too, because they increase the risk of dizziness, fainting and falling among other things. In most cases, safer alternatives exist. Yet the more dangerous drugs continue to be prescribed to millions of older patients.

And, as has been well-documented by the Los Angeles Times and others, powerful painkillers are often misused and overprescribed – with sometimes deadly consequences.

As reporters who have long investigated health care and exposed frightening variations in quality, we wondered why so much secrecy shrouds the prescribing habits of doctors.

The information certainly isn’t secret to drug companies. They spend millions of dollars buying prescription records from companies that purchase them from pharmacies. The drugmakers then use the data to target their pitches and measure success.

But when we tried to purchase the records from the companies that supply them to drug manufacturers, we were told we couldn’t have them — at any price.

We next turned to Medicare, a public program that provides drug coverage to 32 million seniors and the disabled and accounts for one out of every four prescriptions written annually.

We filed a Freedom of Information Act request for prescribing data. After months of negotiation with officials, we were given a list of the drugs prescribed by every health professional to enrollees in Medicare’s prescription drug program, known as Part D.

What we found was disturbing. Although we didn’t have access to patient names or medical records, it was clear that hundreds of physicians across the country were prescribing large numbers of dangerous, inappropriate or unnecessary drugs. And Medicare had done little, if anything, about it.

One Miami psychiatrist, for example, wrote 8,900 prescriptions in 2010 for powerful antipsychotics to patients older than 65, including many with dementia. The doctor said in an interview that he’d never been contacted by Medicare.

A rural Oklahoma doctor regularly prescribed the Alzheimer’s drug Namenda for patients under 65 who did not have the disease. He told us it was because the drug helped calm the symptoms of autism and other developmental disabilities, but there is scant scientific support for this practice.

Among the top prescribers of the most-abused painkillers, we found many who had been charged with crimes, convicted, disciplined by their state medical boards or terminated from state Medicaid programs for the poor. But nearly all remained eligible to prescribe to Medicare patients.

If you or a loved one were a patient of one of these doctors, wouldn’t you want to know this?

We have now taken the data and put it into an online database that allows anyone to look up a doctor’s prescribing patterns and see how they compare with those of other doctors.

This information is just a start. It can’t tell you if your doctor is doing something wrong, but it can give information that allows you to ask important questions.

For instance, why is your doctor choosing a drug that his peers seldom do? Does your doctor favor expensive brand-name drugs when cheaper generics are available? Has your doctor been paid to give promotional talks for drug makers?

And we’d like to see the day when all prescribing by all health professionals – not just in Medicare – is a matter of public record.

It’s not only patients who benefit when medicine is more transparent. Doctors too can gain by comparing themselves to their peers and to those they admire. Clinics can see how their staffs stack up. And researchers can track patterns and examine why doctors prescribe the way they do.

One doctor told us that after studying our online database, he cornered his colleagues and peppered them with questions about their prescribing. Most, he said, were surprised when he told them their drug tallies.

Many aspects of doctors’ practices remain private. The number of tests they order and procedures they perform. The number of times they make mistakes. These data could help inform the public, too.

In the meantime, arming yourself with prescribing information allows you to be more active in your health care or that of an aging or disabled loved one.

Charles Ornstein and Tracy Weber are senior reporters at ProPublica, where this piece was originally co-published with the Los Angeles Times.

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Treatments of Fever
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Well, it is very important to keep a check on the Medicines, which the Doctor Prescribes. If you will be completely unaware of those, you will be more prone to be fooled. Even if you are just suffering from a Fever, you need to take care of the Medicines, which your Doctor Prescribes.
Take Care, and Stay Healthy!

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Austin Turner
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Austin Turner

The easy answer is that you can’t know but I guess if you are faced with a condition you should bridge the knowledge gap as much as possible.
http://www.docboard.org/ok/ok.htm

andy
Guest

Anyone who argues that the medical establishment is in the pocket of the drug companies has their head buried in the sand. And the drug companies have blood on their hands….

Peter1
Guest
Peter1

“We have now taken the data and put it into an online database that allows anyone to look up a doctor’s prescribing patterns and see how they compare with those of other doctors.”

From the description of the patients I doubt any would be interested in looking this up – especially the drug addicts. HIPPA may prevent their relatives from taking any action.

What do people expect for a 10-15 minute office visit except for the quick chemical cure.

David Mokotoff
Guest

The perfect drug could be taken once a day, have no side effects, be cheap, and 100% effective for the condition it was prescribed. The perfect drug does not, and likely will never, exist. All drugs come with side effects. Many of these are known at time of FDA approval, and many are not until after widespread usage by the general public. There are many medications inappropriately prescribed yes. However, our society in general, and patients in particular, demand a “pill for every ill.” This of course does not mean we need to comply with a request, or demand, if… Read more »

ezra klein's shadow
Guest
ezra klein's shadow

I think the premise of Ornstein and Weber is absurd (e.g. that doctors get some sort of secret black cloak over their practice that nobody else benefits from).

While we’re in the interest of full disclosure, why cant I find teh following things on ProPublica’s website?

1. Ornstein and Weber’s salaries
2. The salaries of the board of directors
3. A DETAILED BUDGET of operations
4. A DETAILED breakdown of funding sources

I’d really like this information and it is hard for ProPublica to proclaim itself an “independent” media outlet when they are completely non-transparent.

Dr. Rick Lippin
Guest
Dr. Rick Lippin

The overuse of meds in modern western bio-medicine will surely be recorded in medical history as a great tragedy of excess due to scientific hubris and greed. I call it “a true miracle industry gone completely sour”. We must start with revising medical education away from deifying pharmacologic interventions for everything. There is “no cure for the human condition” We must sentence culpable Big PhRMA CEO’s to serve jail sentences if they are found to be intentionally harming customers/patients. Fines and bad publicity are just not working. A hopeful observation from my practice is that even blue-collar workers are asking… Read more »

Vik Khanna
Guest

This is one of those pieces of “investigative” journalism that is so seductive. No thinking person can oppose more transparency in medical care, right? So, this must be a great idea. And, of course, we should single out physicians, because it’s all their fault (physicians…read carefully, I’m with you on this one). Maybe. Maybe not. People have been talking about — and failing at — health care transparency ever since I got into the industry. Indeed, my first public policy mentor, former Maryland Attorney General and gubernatorial candidate Steve Sachs, in 1986 became first state AG to force the feds… Read more »

Al
Guest
Al

“data from drug company trials posted on the web before approval where not only patients and their doctors, but credible scientists who don’t work with the FDA, can comment on them. ” Vik, my understanding is that pharmaceutical companies provide the studies they wish to the FDA and it is those studies that are reviewed before FDA approval. I would prefer that the pharmaceutical companies be forced to label a study before it is begun as to one that will be sent to the FDA for approval and not permit that study to simply be dumped and unknown. Only those… Read more »

Vik Khanna
Guest

Hi Al: I am in complete agreement that we should know the results of both successful and unsuccessful trials, as well as both studies that were and were not submitted for FDA review.

As for your latter point, unfortunately, I think it is moot. Drug companies know exactly who their top subscribers are and who they gave gifts to. The generous companies and expectant gift receivers are quite voluble with one another, I can assure you.

Al
Guest
Al

I believe that information is provided by the pharmacies and the flow could be stopped.

Charles Ornstein
Guest

Thanks for the great comments so far. We have a lot of additional information on our site (http://projects.propublica.org/checkup/) to provide context and answer FAQs (http://www.propublica.org/article/prescriber-checkup-faq).

Leslie, to your point, we also created a chart on the most used Beers drugs in seniors in the Part D program. It surprised me. Does it surprise you? http://projects.propublica.org/checkup/riskydrugs

Also, be sure to check out the list of the top prescribers of Oxycontin in Part D in 2010. Many have been charged, disciplined, kicked out of Medicaid, etc.: http://projects.propublica.org/checkup/oxycontin

Would welcome additional thoughts.

Leslie Kernisan, MD MPH
Guest

that list re Beers criteria is indeed interesting. I’m not surprised to see so much glyburide prescribed; a little surprised to see so much amitryiptyline. What exactly surprised you? In general I find older people taking a lot of anticholinergics and a lot of NSAIDs, and I do a lot of discontinuing of both. Doesn’t help that both types of drugs are easily available over-the-counter though. Also, I also do a lot of reducing drug doses…for example,last year after careful consideration & conversation w a family we decided to try an anti-psychotic in an elderly parkinson’s patient who had become… Read more »

Leslie Kernisan, MD MPH
Guest

Great post and terrific project! thanks for digging up this information and making it available for all to see. In case anyone is interested in the American Geriatrics Society list of potentially inappropriate medications for older adults, it’s easily available to the public here: http://www.americangeriatrics.org/files/documents/beers/BeersCriteriaPublicTranslation.pdf They also provide a handy tip sheet on how to talk to doctors if one finds one of these medications has been prescribed: http://www.healthinaging.org/files/documents/Medications/Beers_Criteria_Public_QandA_Feb_2012.pdf I’ve found that concerned families really appreciate being able to access the Beer’s criteria, so would love for more people to know it’s available. btw, I cannot review my own prescribing…I… Read more »

Al
Guest
Al

“Seldom are they monitored to see if they are prescribing appropriately”

Physicians are monitored more than you might recognize. Patients, attorneys, health care organizations, second opinions, government agencies, pharmacists, hospital pharmacists, all sorts of committees, just to mention a few. But, the important thing that you mention is so. It is difficult to measure quality.