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

OBJECTIVE: 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.

The impact of utilization management on readmissions among patients with cardiovascular disease.

OBJECTIVE: To determine if prospective utilization reviews that lead to reduced hospital length of stay (LOS) relative to days requested by an attending physician affect the likelihood of readmission for privately insured patients with cardiovascular disease. DATA SOURCES: Data obtained from a private insurance company on utilization management decisions from 1989 through 1993. During this five-year period, 39,117 inpatient reviews were conducted, 4,326 (11.1 percent) on patients with cardiovascular disease. We selected for analysis all 4,326 reviews performed on patients with cardiovascular disease. STUDY DESIGN: We used proportional hazard analysis (Cox regression) to investigate the relationship between LOS reductions relative to days requested by a patient's attending physician and the likelihood of readmission within 60 days of discharge. Separate analyses were performed for medical and procedural admissions. PRINCIPAL FINDINGS: There were 2,813 requests for medical admission, and 1,513 requests for procedural admission. Requests for admission were rarely denied. Length of stay was reduced relative to that requested by the treating physician for 17 percent and 19 percent of medical and procedural admissions, respectively. Cumulative 60-day readmission rates were 9.5 percent for medical admissions and 12.3 percent for procedural admissions. We found no relationship between LOS reduction and the likelihood of readmission for medical admissions. However, patients admitted for procedures who had their length of stay reduced by two or more days were 2.6 times as likely to be readmitted within 60 days as those who had no reduction in their length of stay (95% CI: 1.3-5.1; p < .005). CONCLUSIONS: Utilization management (UM) rarely denies requests for inpatient treatment of cardiovascular disease. The association between LOS reduction and the likelihood of readmission for patients admitted for cardiovascular procedures raises concern that UM may adversely affect clinical outcome for some patients. Further research is needed to definitively elucidate any relationship that might exist between utilization review decisions and quality of care.

Changing physician practice of physical activity counseling.

We conducted a prospective controlled trial to determine whether an educational intervention could improve resident physician self-efficacy and counseling behaviors for physical activity and increase their patients' reported activity levels. Forty-eight internal medicine residents who practiced at a Department of Veterans Affairs hospital received either two workshops on physical activity counseling or no intervention. All residents completed questionnaires before and 3 months after the workshops. The 21 intervention physicians reported increased self-efficacy for counseling and increased frequency of counseling compared with the 27 control physicians. Approximately 10 patients of each resident were included in the study and surveyed before and 6 months after the intervention. Of 560 patients, 465 (83%) returned both questionnaires. Following the intervention, there were no significant differences between patients of intervention and control physicians on any outcome measures. We conclude that educational interventions can improve physicians' reported self-efficacy of physical activity counseling but may not increase patient physical activity levels. Alternative approaches that emphasize overcoming the substantial barriers to exercise in chronically ill outpatients clearly will be important for facilitating changes in physical activity.

The economics of treatment for infants with respiratory distress syndrome.

OBJECTIVES: To define clinical outcomes and prevailing patterns of care for the initial hospitalization of infants at greatest risk for respiratory distress syndrome (RDS); to estimate direct medical care costs associated with the initial hospitalization; and to introduce and demonstrate a simulation technique for the economic evaluation of health care technologies. METHOD: Clinical outcomes and usual-care algorithms were determined for infants with RDS in three birthweight categories (500-1,000g; >1,000-1,500g; and >1,500g) using literature- and expert-panel-based data. The experts were practitioners from major U.S. hospitals who were directly involved in the clinical care of such infants. Using the framework derived from the usual care patterns and outcomes, the authors developed an itemized "micro-costing" economic model to simulate the costs associated with the initial hospitalization of a hypothetical RDS patient. The model is computerized and dynamic; unit costs, frequencies, number of days, probabilities and population multipliers are all variable and can be modified on the basis of new information or local conditions. Aggregated unit costs are used to estimate the expected medical costs of treatment per patient. RESULTS: Expected costs of initial hospitalization per uncomplicated surviving infant with RDS were estimated to be $101,867 for 500-1,000g infants; $64,524 for >1,000-1,500g infants; and $27,224 for >1,500g infants. Incremental costs of complications among survivors were estimated to be $22,155 (500-1,000g); $11,041 (>1,000-1,500g); and $2,448 (>1,500 g). Expected costs of initial hospitalization per case (including non-survivors) were $100,603; $72,353; and $28,756, respectively. CONCLUSIONS: An itemized model such as the one developed here serves as a benchmark for the economic assessment of treatment costs and utilization. Moreover, it offers a powerful tool for the prospective evaluation of new technologies or procedures designed to reduce the incidence of, severity of, and/or total hospital resource use ascribed to RDS.

Effect of changes in the health care system on the career outlook of University of Washington, Seattle, medical students.

We describe how market-oriented and governmental reforms were shaping students' career choice and outlook toward future clinical practice during the 1993-1994 academic year. A random sample of a third of University of Washington, Seattle, medical students (n = 212) was surveyed regarding attitudes toward health care reform, specialty choice, and future clinical practice; 171 responded (81%). Most students (90%) thought that the health care system required fundamental change. An equal proportion favored managed competition and single-payer proposals (40% and 39%, respectively). Most (72%) were confident that they would be able to practice medicine in a professionally satisfying environment. More than half the students interested in specialty careers thought that they might not be able to practice in their chosen field, but only 21% of these were more likely to choose a career in primary care in light of anticipated reforms. Most students were optimistic about their future medical careers. Knowledge of market-oriented reforms exerted little influence on the career decisions of students interested in nonprimary care fields. Medical schools should play a more active role at the undergraduate level so that those students who apply to medical school have a better understanding of the changing nature of health care delivery in this country.

Cost-effectiveness of unenhanced MR imaging vs contrast-enhanced CT of the abdomen or pelvis.

OBJECTIVE: The purpose of this study was to compare the cost of unenhanced MR imaging with that of CT with high- or low-osmolality contrast agents for abdominal or pelvic imaging in patients at risk for nephrotoxic effects induced by contrast material. MATERIALS AND METHODS: Using decision analysis, we evaluated direct medical care costs associated with the use of CT with high- or low-osmolality contrast agents vs MR imaging. We used data from a variety of sources and assumed that the three imaging techniques provide nearly equivalent diagnostic information. The base-case analysis assumed that patients were at low risk (i.e., 2%) for development of nephrotoxic effects. Nephrotoxic effects were defined as increases in the serum level of creatinine of 50% or more above baseline. Our analysis took the perspective of the hospital and used estimated hospital costs, not charges. Sensitivity analyses were performed on risk estimates for development of nephrotoxic effects and for the estimates of medical care costs. RESULTS: For the base case, CT with a high-osmolality contrast agent is the least costly imaging strategy. When the risk of nephrotoxic effects exceeds 5% for high-osmolality contrast agents or 2.6% for low-osmolality contrast agents, then MR imaging is the preferred strategy. The model is relatively insensitive to treatment costs. CONCLUSION: From a hospital's perspective, MR imaging of the abdomen or pelvis is cost minimizing in patients at high risk for nephrotoxic effects induced by contrast agents. Use of low-osmolality contrast agents must reduce the frequency of nephrotoxic effects in high-risk patients by at least 50% to be less costly than MR imaging.

Cost, uncertainty, and doctors' decisions. The case of thrombolytic therapy.

OBJECTIVE: To examine the prescribing patterns and predictors of physician choice in the selection of intravenous thrombolytic therapy for the treatment of acute myocardial infarction. DESIGN: Survey of a random sample of 250 California cardiologists between July 1989 and February 1990. RESULTS: The adjusted response rate was 66%. For a patient presenting within 30 minutes after the onset of an uncomplicated acute anterior-wall myocardial infarction, 98% of respondents reported that they would prescribe a thrombolytic agent, 79% chose tissue plasminogen activator, and 21% chose streptokinase. Users of tissue plasminogen activator were nine times more likely than streptokinase users to perceive tissue plasminogen activator as superior for early coronary artery recanalization, although most users of tissue plasminogen activator and streptokinase perceived no difference between the two agents for improvement in ejection fraction and mortality. Estimates of side effects did not distinguish the two groups. Users of streptokinase were eight times more likely to practice in a health maintenance organization than were users of tissue plasminogen. For a self-paying patient, 36% of users of tissue plasminogen activator said that they would switch to streptokinase, and 27% would switch for a patient insured by Medicaid. CONCLUSIONS: These results indicate that physicians place great emphasis on surrogate end points. Physicians vary in their willingness to use more expensive therapies over cheaper alternatives, even when their perceptions of the relative risks and benefits are similar. The patient's insurance status and the provider's practice setting may exert an important influence on doctors' clinical choices.

Hypoxia inhibits proliferation of fetal pulmonary arterial smooth muscle cells in vitro.

Normal pulmonary arterial development in the relatively hypoxic intrauterine environment and pulmonary arterial remodeling in hypoxic infants include extension of the smooth muscle layer into normally nonmuscular arteries and thickening of the arterial media in the muscular arteries. These changes require proliferation of immature smooth muscle cells or differentiation of smooth muscle cell precursors. Because the mechanisms that regulate these processes have not been clearly defined, we asked whether decreased oxygen tensions could promote either hyperplasia or hypertrophy of smooth muscle cell precursors in vitro. We have studied cells that proliferate and migrate out of explants from the media of the pulmonary arteries of near-term bovine fetuses, because these cells are representative of those that are involved in normal arterial development and possibly also in arterial remodeling. Decreases in oxygen tension within and below the physiologic range do not cause hyperplasia or hypertrophy of these cells. Instead, cell proliferation decreased at oxygen tensions below 60 mm Hg. The effects of hypoxia on proliferation of aortic and pulmonary arterial smooth muscle cells were identical, but effects on proliferation of dermal fibroblasts and endothelial cells were smaller in magnitude and evident only at lower oxygen tensions. These findings suggest that hypoxia does not act directly on smooth muscle cells to produce increased quantities of these cells in the pulmonary arteries during normal prenatal development or during remodeling of the pulmonary arteries of the hypoxic neonate, implying that other factors mediate these phenomena.

Heparin inhibits proliferation of fetal vascular smooth muscle cells in the absence of platelet-derived growth factor.

Proliferation of smooth muscle cells from the pulmonary arteries and aortas of fetal calves is inhibited by heparin in vitro. This effect is reversible and dose dependent. Comparisons with effects of other polysaccharides indicate that only extensively sulfated polysaccharides inhibit proliferation of smooth muscle cells but that specific structural features of heparin are required to achieve maximum effect. Heparin-Sepharose chromatography of medium containing fetal calf serum reduces the ability of that medium to promote growth of smooth muscle cells from fetal pulmonary arteries, suggesting that heparin may remove soluble growth factors in serum. However, inhibition of fetal pulmonary artery smooth muscle cell proliferation by heparin is identical in media supplemented either with serum prepared from fetal calf plasma, in which platelet-derived growth factor (PDGF) is not detectable, or with fetal calf serum, which contains relatively abundant PDGF (114 pg/ml). Thus, inhibition of fetal pulmonary artery smooth muscle cell proliferation by heparin is not mediated solely by decreased availability or activity of exogenous PDGF. These studies suggest that morphogenesis of the smooth muscle investment of the pulmonary arteries could be regulated by local production of heparin-like inhibitors of smooth muscle cell growth.