Posted by phillipa on September 18, 2012, at 18:26:09
Something we didn't already know. The pharmactacal Industry Is Influencing Physician Practices & Guideline Through Incentives. 5 meds or more considered polypharmacy. Phillipa
From Medscape Medical News
Pharmaceutical Industry Influences Practice and Guidelines
Larry Hand
Authors and Disclosures
September 14, 2012 Individuals with financial conflicts should be excluded from involvement with medical practice guideline writing, regardless of disclosure, and physicians should be discouraged from meeting with drug company representatives, according to an article published in the September/October issue of the Annals of Family Medicine.
Linda M. Hunt, PhD, from the Department of Anthropology, Michigan State University, East Lansing, and colleagues analyzed the management of patients with type 2 diabetes and hypertension in 44 primary care centers in Michigan during 2009 and 2010. They conducted interviews with 58 physicians, nurse practitioners, and physician assistants, observed 107 clinical consultations with 12 clinicians in 6 clinics, and interviewed 70 patients treated by those 12 clinicians.
Sixty-two (89%) of the patients said they took multiple medications, with 36 (51%) of the 70 taking 5 or more medications, which is a threshold commonly used to define polypharmacy. Such medication use reflects a US trend of prescription drug use that has increased 6-fold since 1990. Adverse drug reactions reported by the Food and Drug Administration tripled between 1995 and 2005, the researchers write. In addition, lower diagnostic guideline criteria introduced over the years has resulted in an increase in the number of people diagnosed with and being treated for chronic diseases such as diabetes and hypertension, and even prediabetes, they write.
"We noted a common scenario: patients began medications after having moderately elevated test results (often at levels considered normal just a few years ago), developed additional symptoms, were found to have values falling outside reference ranges on other tests, and were prescribed more drugs," the researchers write. "They were expected to continue these medications permanently: their target laboratory levels could be achieved only through continued use of these drugs."
The clinical consultations the researchers observed "focused heavily on" medication prescriptions with little or no discussion of other treatment paths including diet and exercise, the authors write.
Of the 58 clinicians involved, 39 (67%) said they relied on clinical guidelines when prescribing, and only 4 (7%) questioned the clinical soundness of guidelines. All clinicians reported prescribing combinations of at least 2 drugs for hypertension or diabetes, and 25 (43%) often combined 3 or more drugs. "Furthermore, once a patient has a diabetes diagnosis, the goal numbers for hypertension and cholesterol are lower, so additional medications will be prescribed, quickly multiplying prescriptions," the researchers write, saying this illustrates a so-called "prescribing cascade."
Heavy Marketing by Pharmaceutical CompaniesThe authors also note that clinicians are exposed to heavy marketing efforts by pharmaceutical companies, and that this, combined with pay-for-performance programs, may be contributing to the emphasis on medication prescriptions. Of the 53 clinicians willing to discuss pharmaceutical marketing, 38 (72%) reported having regular contacts with pharmaceutical representatives, with 33 (62%) of these clinicians seeing 10 representatives weekly and 41 (77%) finding the representatives' information useful.
The 70 patients in this study were taking an average of 4.8 medications, with 42 (60%) taking medications for disorders in addition to hypertension or diabetes, and 24 (57%) of those patients "taking additional medications for respiratory or gastric symptoms well-known adverse effects of hypertension and diabetes medications," the researchers write. Almost 70% (47) of the patients said they had experienced symptoms of adverse drug reactions from diabetes or hypertension medications, yet all but 1 physician in the study mentioned prescribing fewer drugs, most concentrating on either adding or changing prescriptions.
Patients also voiced many concerns about affordability of such medication prescriptions.
In addition to influencing clinicians' decisions, pharmaceutical companies may also have influence on the establishment of guidelines physicians consult when making medication decisions, the researchers write. "[T]he committees and organizations setting the standards often have substantial pharmaceutical industry support and include many individuals with industry ties," the researchers write.
At a minimum, they write, such industry-tied individuals should be excluded from guideline writing, physicians should be discouraged from seeing industry representatives, and pay-for-performance programs should be monitored for "evidence of unintended negative effects on patients."
They conclude, "Together, these policy changes may slow the disturbing trends our findings illustrate."
This study was supported by a grant from the National Institutes of Health, National Center for Human Genome Research. The authors have disclosed no relevant financial relationships.Emerg Infect Dis. 2012;10:452-460.
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