Efficiency is a Problem: Irrational Use of Medicines

OpEdNews  2/18/2014

By zhenchao ren


My PCP recently prescribed me azithromycin for the "sore throat" without obvious symptom of fever at an urgent-care encounter of esophageal reflux; and my parents had to take Lipitor just because their cholesterol levels were a little bit over the normal value for the first time. As a laboratory technologist in transfusion medicine and clinical diagnosis, I saw many clinicians ordering blood products without reading laboratory test results, making unreasonable platelet orders for suspected low platelet counts, and requesting overdosed human-factor derivatives to stop excessive bleeding. The obstetricians and gynecologists failed to inform Rh-negative pregnant women about why they had to have a Rhogam shot. Inefficiency is prevalent in the U.S. healthcare system, which adds costs and undermines quality, and raises questions about how Americans pay for future health-care needs.

The Institute of Medicine (IOM) estimated about 25% of the approximate annual $3 trillion healthcare expenditure was wasted; therefore, it's time to improve cost-effective clinical practice while getting the most for our health- care dollars. United States not only spends much more per capita on health care, but also has one of the highest expenditure growth rates, where both public and private health expenditures are growing at a rate that exceeds other developed countries. Despite this higher level of spending, the United States does not achieve better score on many important health measures.

World Health Organization (WHO) estimated about more than half of all medicines were prescribed, dispensed, or sold inappropriately, and that half of all patients failed to take them correctly; the overuse, underuse, or misuse of medicines resulted in wastage of scarce resources and widespread health hazards. Examples of irrational use of medicines include use of too many prescribed medicines per patient; inappropriate use of antimicrobials, often in inadequate dosage, for non-bacterial infections; over-use of IV injections when oral formulations would be more appropriate; failure to prescribe in accordance with standard clinical guidelines; inappropriate self-medication, often of prescription-only medicines; non-adherence to dosing regimes. According to a 2013 report from American Society of Clinical Oncology (ASCO), 80% of oncologists strongly or somewhat agreed that "more use of cost-effectiveness data in coverage and payment decisions for cancer drug is needed" and 79% felt "more government research on comparative effectiveness of cancer drugs is needed," yet only 42% felt "well prepared to interpret of use cost-effectiveness information in my treatment decisions." A 2014 report about antibiotics prescribing to adults with sore throat in the United States from 1997-2010, which revealed that despite vigilant efforts by the Centers for Disease Control and Prevention (CDC) and others to reduce inappropriate prescription of antibiotics for sore throats in the last 20 years, little to no progress has been made. Even though only about 10% of sore throats are due to group A Streptococcus (GAS) infection, 60% of patients with sore throats were treated with antibiotics, the report concluded that the unnecessary antibiotic prescribing spent about $500 million and antibiotics had been up to 40 times more expensive during that period, the developing side effects of diarrhea in 5% to 25% of those cases. The prescription of broader-spectrum, more expensive antibiotics is common, such as azithromycin; but prescribing of penicillin remains infrequent, which is clinical guideline-recommended, inexpensive, well-tolerated, and to which GAS is universally susceptible. Additionally, a new CDC report provided that more than 2 million people in the United States became infected with organisms that were resistant to antibiotics, leading to considerable disability, death, and economic cost.

Comparative effectiveness research (CER) compares the benefits of various treatment and diagnostic modalities to each other, and enhances physician judgment to provide the right treatment at the right time. Patient Protection and Affordable Care Act (PPACA) creates the Patient-Centered Outcomes Research Institute (PCORI), an independent, not-for-profit entity that is tasked with supporting the CER studies. While PCORI is conducting research to compare various clinical treatments to determine which is more cost-effective, CER findings may not be used to create clinical standard guidelines, mandate treatments or deny coverage for any service. Unlike many other developed nations in Europe, the U.S. has not systematically implemented and validated CER with altering the prescribing patterns to eliminate disparity in health outcomes and control the growth of healthcare spending. Validating the CER studies in the development of clinical practice guideline, which enables healthcare providers to determine a better patient-focused, cost-efficient, and evidence-based alternative so that they do not have to make decisions just at bedside; moreover, CER provides evidence of an intervention's value with cost considerations and addresses whether cost-increasing prescription represents a decent value of health outcome over time. The Hippocratic Oaths states that "so long as I maintain this Oath faithfully and without corruption, may it be granted to me to partake of life fully and the practice of my art, gaining the respect of all men for all time", which requires healthcare providers to obey the principle of "rational use of medicines." A rational use of medicines defines that patients receive medications appropriate to their clinical needs, in doses that meet their own individual requirements, for an adequate period of time, and at the lowest cost to them and their community.

Rational use of medicines strategy and monitoring: Advocates rational use of medicine by identifying and formulating successful programs and strategies, and supports the responsible utilization of CER studies. Aetna partnered with the US Oncology Network for a shared-savings program that required physicians to use a software system that provided clinical-decision support and documentation of the use of clinical guidelines for patients with lung, breast, and colon cancers; the insurers reported the program reduced costs by 12%, including a 40% drop in emergency-room visits and a 17% decrease in hospital admission in 2012.

Rational use of medicines by health professionals: Collaborates with different healthcare professionals to develop a clinical standard guideline from the CER. Healthcare professionals have to envision themselves as an integrated healthcare-delivery system to utilize a technique called "a treatment map", where different healthcare professionals list their tasks and look at best treatment alternative from the patients' perspective. The New York City Health and Hospitals Corp. had formed a comprehensive cancer center in several of its largest facilities, enabling its providers to deliver care in a multidisciplinary way.

Rational use of medicines by consumers: Supports an effective patient-oriented healthcare system of medical information, empowering patients to make responsible decisions on their healthcare-delivery option from the disclosure of CER studies. A 2011 CMS report stated that California, Illinois, Massachusetts, Ohio, and Virginia were requiring each managed-care plan in their dual demonstration to create at least one consumer-advisory committee that had the ear of the governing board; Illinois required plan officials to meet quarterly with the committee.

In the end, healthcare efficiency is about Americans' lives and livelihoods, and the promise of the US healthcare system for future. Let's support the validation of CER to achieve a better value than ever before, and make sure that the USA is on a more sustainable spending path.