In the News

Best practice advice on generics, postdischarge facilities and spending, and more.

Best practice advice says generics can improve adherence, save money

Prescribing generics instead of brand-name drugs can improve adherence and also cut costs, according to recent best practice advice from ACP.

ACP's Clinical Guidelines Committee conducted a literature search in 2014 with the goal of helping internists and other clinicians make high-value, cost-conscious choices regarding use of generic drugs. They found that most (although not all) studies examining the effect of generics versus brand-name drugs on adherence in chronic disease showed better long-term adherence with the former. The evidence also indicated that brand-name medications do not appear to have an efficacy advantage when compared with molecularly identical generic drugs and that use of generic drugs decreases patients' out-of-pocket costs.

The main barriers to more widespread of use of generic drugs are physicians' perceptions about their safety and efficacy and patients' expectations and preferences, the committee noted. Tiered formulary copayment systems, education of physicians and patients, prior authorization and step therapy requirements, physician performance measures, and use of electronic health records to notify physicians about formulary status and out-of-pocket costs are all strategies that could increase use of generics, the committee wrote, although it noted that the evidence base supporting such strategies can be limited.

The committee provided the following talking points for clinicians to use in conversations with patients:

  • Brand-name medications are not necessarily more efficacious.
  • The generic versions of a particular brand-name medication may come in different shapes, sizes, and colors but offer the same benefit.
  • Dosage levels vary for different medications, including brand-name and generic alternatives that are used to treat the same condition, and similar dosages may not necessarily achieve the same outcome.
  • Changing from brand-name to generic medication reduces patient costs.
  • Changing from a generic medication to a brand-name medication is rarely indicated in patients with chronic diseases that are already well-controlled.

The committee concluded that clinicians should prescribe generic medications instead of more expensive brand-name medications when possible. They noted that more research is needed on the comparative safety and effectiveness of generics compared to brand-name drugs, as well on the best strategies to increase generic use. The best practice advice paper was published by Annals of Internal Medicine on Jan. 5.

Postdischarge facilities best target for reducing bundled spending, studies find

The increasing importance of postdischarge care to hospital reimbursement was analyzed by 2 recent studies.

In the first study, researchers compared low-, medium-, and high-cost hospitals under the Medicare Spending per Beneficiary metric of the Hospital Value-Based Purchasing program. The metric includes all Medicare Part A and B payments from 3 days prior to hospitalization through 30 days after discharge. A total of 3,194 hospitals participating in the fiscal year 2014-2015 program were included. The results were published as a research letter in the January JAMA Internal Medicine.

Overall, preadmission spending was responsible for 3% of the average total episode cost (which was $18,247), compared to 53% from inpatient spending and 44% from postdischarge care. Of the postdischarge component, 38% was spent on skilled nursing facilities and 30% on readmissions. Only 4% of the hospitals met the metric's benchmark to be considered low-cost, while 51% were medium cost and 45% were high cost. Researchers found that the difference between high- and low-cost hospitals was driven primarily by postdischarge care; patients at the former spent $9,287 on postdischarge care compared to $4,596 at the latter. Changes in hospitals' cost categories were also driven largely by changes in postdischarge spending, the study also found, leading the authors to conclude that “hospitals that can reduce postdischarge spending will perform well on CMS’ new spending measure.”

Another research letter published in the same issue of JAMA Internal Medicine analyzed 1 hospital's efforts to reduce postdischarge spending. It reported on an initiative to shift referrals from facility-based postacute care to home-based care for Medicare patients undergoing cardiac valve replacement, major joint replacement in the lower extremities, and spinal fusion. The percentage of patients going to postacute facilities dropped significantly for cardiac surgery (from 70.5% to 21.1%; adjusted odds ratio [AOR], 0.11) and joint replacement (from 67.6% to 33.5%; AOR, 0.26), with less change seen in spinal fusion patients (40.3% to 29.8%; AOR, 0.69). Meanwhile, readmission rates remained steady for cardiac and spinal fusion patients and dropped significantly for joint replacement. The results show that postdischarge care might be shifted from facilities to home without increases in readmissions or length of stay and “raise questions about the value of providing postacute care services in facilities where care is more costly and potentially more disruptive to the lives of patients and families,” the authors said.

An accompanying commentary noted that hospitals will have to focus on postacute care “as the most viable lever for reducing spending.” It called for hospitals to develop preferred provider networks of skilled nursing facilities involving closer collaboration on the care of these patients. Hospitals should also share financial risk with the skilled nursing facilities that receive their patients, the commentary suggested.

Recommendations released on sharing decision making in critical care

Recommendations on shared decision making in critical care were released jointly recently by the American College of Critical Care Medicine and American Thoracic Society.

The recommendations were based on an expert committee's review of empirical research and normative analyses published in peer-reviewed journals. The authors noted that although shared decision making is endorsed by organizations and clinicians, there remains confusion about how to implement it. It is particularly challenging in the acute care setting, due to factors such as time pressure, absence of pre-existing relationships between clinicians and patients, and the need for surrogate decision makers, they said.

The statement included 6 points:

  • Shared decision making is defined as a collaborative process that allows patients, or their surrogates, and clinicians to make health care decisions together, taking into account the best scientific evidence available, as well as the patient's values, goals, and preferences;
  • Clinicians should engage in a shared decision making process to define overall goals of care (including decisions regarding limiting or withdrawing life-prolonging interventions) and when making major treatment decisions that may be affected by personal values, goals, and preferences;
  • Clinicians should use as their “default” approach a shared decision making process that includes 3 main elements: information exchange, deliberation, and making a treatment decision;
  • A wide range of decision-making approaches are ethically supportable, including patient- or surrogate-directed and clinician-directed models. Clinicians should tailor the decision-making process based on the preferences of the patient or surrogate;
  • Clinicians should be trained in communication skills; and
  • Research is needed to evaluate decision-making strategies.

The recommendations also offered more specifics on communication skills, including example language for speaking to patients and families. The authors also noted that patients and surrogates have varying preferences regarding their role in decision making, and these preferences may change over time, so clinicians should adapt their decision-making models on an individual basis. The statement was published in the January Critical Care Medicine.

Study finds one-third of medical residents screen positive for depression or its symptoms

Nearly one-third of medical residents screened positive for depression or depressive symptoms, according to a meta-analysis of more than 17,000 physicians in training.

Researchers conducted the systematic review and meta-analysis of 54 studies involving 17,560 physicians. Included studies had information on the prevalence of depression or depressive symptoms among resident physicians, were published between January 1963 and September 2015, and used a validated method to assess for depression or depressive symptoms. Three studies used clinical interviews, and 51 used self-report instruments. Results appeared in the Dec. 8, 2015, Journal of the American Medical Association.

The overall pooled prevalence of depression or depressive symptoms was 28.8% (4,969 of 17,560 individuals; 95% CI, 25.3% to 32.5%), with high between-study heterogeneity. Prevalence estimates ranged from 20.9% according to the 9-item Patient Health Questionnaire with a cutoff of 10 or more (741 of 3,577 individuals; 95% CI, 17.5% to 24.7%) to 43.2% for the 2-item PRIME-MD (1,349 of 2,891 individuals; 95% CI, 37.6% to 49.0%). The prevalence of depression increased each baseline survey year (slope=0.5% increase per calendar year, adjusted for assessment modality; 95% CI, 0.03% to 0.9%, P=0.04).

In a secondary analysis of 7 longitudinal studies, the median absolute increase in depressive symptoms with the onset of residency training was 15.8% (range, 0.3% to 26.3%; relative risk, 4.5). No statistically significant differences were observed between cross-sectional versus longitudinal studies, studies of only interns versus only upper-level residents, or studies of nonsurgical versus both nonsurgical and surgical residents.

“Because the development of depression has been linked to a higher risk of future depressive episodes and greater long-term morbidity, these findings may affect the long-term health of resident doctors. Depression among residents may also affect patients, given established associations between physician depression and lower-quality care,” the authors wrote.

An editorial noted that the prevalence of depression in residents is a marker for deeper and more profound problems. “The solutions to this endemic can be classified into 3 categories: provide more and better mental health care to depressed physicians and those in training, limit the trainees' exposure to the training environment and system that are thought to contribute at least in part to poorer mental health and wellness, and consider the possibility that the medical training system needs more fundamental change,” the editorial stated.