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Patient Requests for Specific Drugs Have Major Influence on Prescribing

Direct-to-consumer advertising may increase medication costs, study finds

Patient requests for specific medications — including requests for brand-name drugs spurred by direct-to-consumer (DTC) advertising — have a substantial effect on doctors’ prescribing decisions, according to a study in the April issue of Medical Care.

“A patient request for a specific medication dramatically increases the rate at which physicians prescribe that medication,” said lead investigator John B. McKinlay, PhD. He added: “These results highlight potential negative impacts of DTC advertising and other forms of activation in medication requests.”

The researchers designed a study to evaluate the effects of “activated” patient requests for specific medications. They made videos in which professional actors portrayed patients with two common, painful conditions: sciatica causing back and leg pain or osteoatrthritis (OA) causing knee pain.

Half of the sham patients with sciatica specifically requested oxycodone, a strong narcotic painkiller, and half of the patients with knee arthritis requested the prescription drug Celebrex (celecoxib, Pfizer). The other half of the patients in both groups requested “just something to make it better.”

The patients requesting oxycodone said they had tried their spouse’s leftover medication; those requesting Celebrex said they saw it advertised, and that a co-worker took it and said it really helped. The video scenarios were randomly shown to 192 primary care physicians, who were then asked a series of questions about diagnosis and management, including what treatment they would recommend.

The results suggested that “activated” patient requests for drugs had a strong effect on recommended treatments. About 20% of sciatica patients requesting oxycodone received it, compared with only 1% of those making no specific request. Strong narcotic pain relievers, such as oxycodone, are generally not recommended for sciatica, particularly for newly presenting patients, as was the case in these scenarios.

Further, about half of the patients with knee OA requesting Celebrex received that drug, compared with one-fourth of the patients requesting no specific medication. Nonsteroidal anti-inflammatory drugs (NSAIDs) such as Celebrex are recommended for the treatment of knee OA. However, the brand-name drug Celebrex is a so-called “selective” NSAID that is much more expensive than other options, with no additional benefit. The patient’s gender, race/ethnicity, or socioeconomic status had no effect on the physicians’ inclination to grant patients’ requests.

Even if they didn’t receive the specific drug they requested, treatment patterns differed for patients who made active requests. “Patients requesting oxycodone were more likely to receive a strong narcotic and were less likely to receive a weak narcotic,” according to the authors. “Patients requesting Celebrex were much less likely to receive a non-selective NSAID.”

The findings add to concerns regarding the potential safety and economic impact of prescription drug requests driven by DTC advertising. The U.S. is one of only two countries that permit DTC advertising — familiar to television viewers as “Ask Your Doctor” ads — for prescription drugs.

There is continued debate over the effect of DTC advertising. “Supporters defend the practice as a way to empower consumers, while opponents argue that commercially motivated messages lead to inappropriate patient requests for medication,” commented Dr. G. Caleb Alexander, Deputy Editor of Medical Care. “In order to resolve this debate, more research is needed to determine the effects of DTC advertising on patient and physician behavior, especially how it affects prescribing decisions and health outcomes.”

The new report is one of the few experimental studies to evaluate the effect of DTC advertising. Since this advertising is frequently used for expensive medications, patient requests for specific medications “activated” by ads are likely to increase medication costs, the authors say.

In addition, some activated requests may sometimes lead to suboptimal care — for example, patients receiving oxycodone for sciatica or Celebrex for arthritis might experience more side effects compared with alternative medications.

“The results highlight the ongoing need for improving strategies for patient–physician communication,” the authors conclude.

Source: Medical Xpress; March 14, 2014.

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