Brand Name Statin Prescribing in a Resident Ambulatory Practice: Implications for Teaching Cost-Conscious Medicine

摘要

What was known There are calls to enhance residents' awareness of the cost implications of their therapeutic decisions.;What is new A study assessed factors at the resident and encounter level that resulted in residents prescribing generic rather than brand name statins for lipid-lowering therapy.;Limitations Small sample, single institution study, and cross-sectional design reduce the ability to generalize.;Bottom line Medical school graduation origin and being in the primary care versus categorical track had an impact on statin-prescribing practices.;Introduction Health care costs in the United States were $2.6 trillion in 2010 and are predicted to rise to $4.6 trillion by 2020.1 As a result, there have been calls to incorporate cost awareness into graduate medical education.2,3 Past efforts to teach residents about costs focused mainly on the inpatient setting,4 and we know relatively little about factors driving resource utilization in residency.5,6 The limited information available about the drivers of resident ordering behavior may be 1 reason why educational interventions to improve cost-effective care among residents have not been successful.7,8 To better understand physician resource utilization patterns as they develop during medical training, we decided to focus on 1 of the “Top 5” practices that may be overused in internal medicine. The Top 5 list for internal medicine was developed in 2011 by the National Physician Alliance.9 This initiative later morphed into the American Board of Internal Medicine's Choosing Wisely campaign.10 The Top 5 list for internists included a recommendation to use generic statins rather than brand name statins when initiating lipid-lowering therapy.11,12 In 2009, brand name statin prescribing was estimated to account for $5.8 billion in annual costs.13 This study was designed to address 2 questions: (1) Was there variation in brand name versus generic statin prescribing when initiating cholesterol-lowering therapy by residents in an urban academic medical center? and (2) What resident characteristics were associated with higher rates of brand name statin prescribing?;Methods We performed a retrospective, cross-sectional analysis of statin prescribing by internal medicine residents at Weill Cornell Internal Medicine Associates—the resident and attending practice of the New York Presbyterian/Weill Cornell internal medicine residency program. We obtained data from the practice's electronic health record for all patient encounters between July 1, 2010, and June 30, 2011 (including office visits, telephone encounters, and order-only encounters), where a statin was prescribed for a patient not previously receiving statin therapy. We selected this time interval because it predated generic availability of atorvastatin; therefore, all prescriptions for atorvastatin and rosuvastatin were for brand name Lipitor and Crestor, respectively. The study period also predated the US Food and Drug Administration's announcement about increased risk of muscle injury with high-dose simvastatin in June 2011. Because we were interested in residents' initial choice of statin, we only included encounters in which the resident initiated statin therapy for a patient who was already established in the practice (for any indication). We excluded encounters in which the statin was refilled because this may not have reflected resident's choice of medication. We also excluded encounters for new patients because we were unable to distinguish whether the patient came to that visit already taking a statin (started by a previous doctor), with the resident just continuing the prior medication, or whether the resident initiated new statin therapy for the patient. Prescriptions that were later changed or discontinued (eg, if the patient or insurance company requested a change) were included in the analysis because our aim was to study initial prescribing behavior by the resident rather than the final statin obtained by the patie