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Barrett AK, Cashy JP, Thorpe CT, Hale JA, Suh K, Lambert BL, Galanter W, Linder JA, Schiff GD, Gellad WF. Latent Class Analysis of Prescribing Behavior of Primary Care Physicians in the Veterans Health Administration. J Gen Intern Med 2022; 37:3346-3354. [PMID: 34993865 PMCID: PMC9550922 DOI: 10.1007/s11606-021-07248-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Accepted: 10/25/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND Benzodiazepines, opioids, proton-pump inhibitors (PPIs), and antibiotics are frequently prescribed inappropriately by primary care physicians (PCPs), without sufficient consideration of alternative options or adverse effects. We hypothesized that distinct groups of PCPs could be identified based on their propensity to prescribe these medications. OBJECTIVE To identify PCP groups based on their propensity to prescribe benzodiazepines, opioids, PPIs, and antibiotics, and patient and PCP characteristics associated with identified prescribing patterns. DESIGN Retrospective cohort study using VA data and latent class regression analyses to identify prescribing patterns among PCPs and examine the association of patient and PCP characteristics with class membership. PARTICIPANTS A total of 2524 full-time PCPs and their patient panels (n = 2,939,636 patients), from January 1, 2017, to December 31, 2018. MAIN MEASURES We categorized PCPs based on prescribing volume quartiles for the four drug classes, based on total days' supply dispensed of each medication by the PCP to their patients (expressed as days' supply per 1000 panel patient-days). We used latent class analysis to group PCPs based on prescribing and used multinomial logistic regression to examine patient and PCP characteristics associated with latent class membership. KEY RESULTS PCPs were categorized into four groups (latent classes): low intensity (23% of cohort), medium-intensity overall/high-intensity PPI (36%), medium-intensity overall/high-intensity opioid (20%), and high intensity (21%). PCPs in the high-intensity group were predominantly in the highest quartile of prescribers for all four drugs (68% in the highest quartile for benzodiazepine, 86% opioids, 64% PPIs, 62% antibiotics). High-intensity PCPs (vs. low intensity) were substantially less likely to be female (OR: 0.30, 95% CI: 0.21-0.42) or practice in the northeast versus other census regions (OR: 0.10, 95% CI: 0.06-0.17). CONCLUSIONS VA PCPs can be classified into four clearly differentiated groups based on their prescribing of benzodiazepines, opioids, PPIs, and antibiotics, suggesting an underlying typology of prescribing. High-intensity PCPs were more likely to be male.
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Affiliation(s)
- Alexis K Barrett
- VA Center for Medication Safety/Pharmacy Benefits Management Services, U.S. Department of Veteran Affairs, Hines, IL, USA.
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, USA.
| | - John P Cashy
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, USA
| | - Carolyn T Thorpe
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, USA
- Division of Pharmaceutical Outcomes and Policy, Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Jennifer A Hale
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, USA
| | - Kangho Suh
- Department of Pharmacy and Therapeutics, University of Pittsburgh, Pittsburgh, PA, USA
| | - Bruce L Lambert
- Department of Communication Studies, Center for Communication and Health, Northwestern University, Evanston, IL, USA
| | - William Galanter
- Department of Medicine, Department of Pharmacy Systems, Outcomes & Policy, University of Illinois at Chicago, Chicago, IL, USA
| | - Jeffrey A Linder
- Division of General Internal Medicine and Geriatrics, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Gordon D Schiff
- Center for Patient Safety Research and Practice, Brigham and Women's Hospital, Boston, MA, USA
- Center for Primary Care, Harvard Medical School, Boston, MA, USA
| | - Walid F Gellad
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, USA
- Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
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Gomes FA, Milev R, Yatham LN, Berk M, Brietzke E. Why do medications with little or no efficacy continue to be prescribed in the management of patients with bipolar disorder? Bipolar Disord 2021; 23:541-543. [PMID: 34297457 DOI: 10.1111/bdi.13114] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Revised: 06/29/2021] [Accepted: 07/02/2021] [Indexed: 12/26/2022]
Affiliation(s)
- Fabiano A Gomes
- Department of Psychiatry, Queen's University School of Medicine, Kingston, ON, Canada.,Centre for Neuroscience Studies (CNS), Queen's University, Kingston, ON, Canada.,Kingston Health Sciences Centre, Kingston, ON, Canada
| | - Roumen Milev
- Department of Psychiatry, Queen's University School of Medicine, Kingston, ON, Canada.,Centre for Neuroscience Studies (CNS), Queen's University, Kingston, ON, Canada.,Providence Care Hospital, Kingston, ON, Canada
| | - Lakshmi N Yatham
- Department of Psychiatry, University of British Columbia, Vancouver, BC, Canada
| | - Michael Berk
- School of Medicine, Deakin University, IMPACT, The Institute for Mental and Physical Health and Clinical Translation, Barwon Health, Geelong, VIC, Australia
| | - Elisa Brietzke
- Department of Psychiatry, Queen's University School of Medicine, Kingston, ON, Canada.,Centre for Neuroscience Studies (CNS), Queen's University, Kingston, ON, Canada.,Kingston Health Sciences Centre, Kingston, ON, Canada
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Butler EL, Laber EB, Davis SM, Kosorok MR. Incorporating Patient Preferences into Estimation of Optimal Individualized Treatment Rules. Biometrics 2018; 74:18-26. [PMID: 28742260 PMCID: PMC5785589 DOI: 10.1111/biom.12743] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2016] [Revised: 05/01/2017] [Accepted: 06/01/2017] [Indexed: 11/29/2022]
Abstract
Precision medicine seeks to provide treatment only if, when, to whom, and at the dose it is needed. Thus, precision medicine is a vehicle by which healthcare can be made both more effective and efficient. Individualized treatment rules operationalize precision medicine as a map from current patient information to a recommended treatment. An optimal individualized treatment rule is defined as maximizing the mean of a pre-specified scalar outcome. However, in settings with multiple outcomes, choosing a scalar composite outcome by which to define optimality is difficult. Furthermore, when there is heterogeneity across patient preferences for these outcomes, it may not be possible to construct a single composite outcome that leads to high-quality treatment recommendations for all patients. We simultaneously estimate the optimal individualized treatment rule for all composite outcomes representable as a convex combination of the (suitably transformed) outcomes. For each patient, we use a preference elicitation questionnaire and item response theory to derive the posterior distribution over preferences for these composite outcomes and subsequently derive an estimator of an optimal individualized treatment rule tailored to patient preferences. We prove that as the number of subjects and items on the questionnaire diverge, our estimator is consistent for an oracle optimal individualized treatment rule wherein each patient's preference is known a priori. We illustrate the proposed method using data from a clinical trial on antipsychotic medications for schizophrenia.
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Affiliation(s)
- Emily L Butler
- Department of Biostatistics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, U.S.A
| | - Eric B Laber
- Department of Statistics, North Carolina State University, Raleigh, North Carolina, U.S.A
| | - Sonia M Davis
- Department of Biostatistics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, U.S.A
| | - Michael R Kosorok
- Department of Biostatistics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, U.S.A
- Department of Statistics and Operations Research, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, U.S.A
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Anderson TS, Lo-Ciganic WH, Gellad WF, Zhang R, Huskamp HA, Choudhry NK, Chang CCH, Richards-Shubik S, Guclu H, Jones B, Donohue JM. Patterns and predictors of physician adoption of new cardiovascular drugs. HEALTHCARE-THE JOURNAL OF DELIVERY SCIENCE AND INNOVATION 2017; 6:33-40. [PMID: 29066168 DOI: 10.1016/j.hjdsi.2017.09.004] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/11/2017] [Revised: 09/22/2017] [Accepted: 09/22/2017] [Indexed: 11/19/2022]
Abstract
BACKGROUND Little is known about physicians' approaches to adopting new cardiovascular drugs and how adoption varies between drugs of differing novelty. METHODS Using data on dispensed prescriptions from IMS Health's Xponent™ database, we created a cohort of all primary care physicians (PCPs) and cardiologists in Pennsylvania who regularly prescribed anticoagulants, antihypertensives and statins from 2007 to 2011. We examined prescribing of three new cardiovascular drugs of differing novelty: dabigatran, aliskiren and pitavastatin. Outcomes were rapid adoption of each new drug, defined by early and sustained monthly prescribing detected by group-based trajectory models, by physicians within the first 15 months of marketplace introduction. RESULTS 5953 physicians regularly prescribed each drug class. The majority of physicians (63.8%) adopted zero new drugs in the first 15 months, 35.0% rapidly adopted one or two, and 1.2% rapidly adopted all three. Physicians were more likely to rapidly adopt the most novel drug, dabigatran (27.3%), than aliskiren (10.5%) or pitavastatin (8.0%). Physician specialty and sex were the most consistent predictors of adoption. Compared to PCPs, cardiologists were more likely to rapidly adopt dabigatran (Adjusted Odds Ratio 8.90, 95% confidence interval 7.42-10.67; P<0.001) aliskerin (2.05, CI 1.56-2.69; P<0.001) and pitavastatin (3.44, CI 2.60-4.57; P<0.001). Female physicians were less likely to adopt dabigatran (0.71, CI 0.59-0.85; P <0.001) and aliskiren (0.64, CI 0.49-0.83; P <0.001). CONCLUSIONS Physicians vary in their prescribing of recently-introduced cardiovascular drugs. Though most physicians did not rapidly adopt any new cardiovascular drugs, drug novelty and cardiology training were associated with greater adoption.
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Affiliation(s)
- Timothy S Anderson
- Division of General Internal Medicine, University of California, San Francisco, USA
| | - Wei-Hsuan Lo-Ciganic
- Department of Pharmacy, Practice and Science, College of Pharmacy University of Arizona, USA
| | - Walid F Gellad
- Division of General Internal Medicine at University of Pittsburgh School of Medicine; Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, USA
| | - Rouxin Zhang
- Department of Health Policy and Management, University of Pittsburgh Graduate School of Public Health, 130 DeSoto Street, Crabtree Hall A613, Pittsburgh, PA 15261, USA
| | | | - Niteesh K Choudhry
- Division of Pharmacoepidemiology and Pharmacoeconomics and Center for Healthcare Deliver Sciences, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, USA
| | - Chung-Chou H Chang
- Division of General Internal Medicine at University of Pittsburgh School of Medicine, USA
| | | | - Hasan Guclu
- Department of Statistics, School of Engineering and Natural Sciences, Istanbul Medeniyet University, Istanbul, Turkey
| | - Bobby Jones
- Department of Psychiatry, University of Pittsburgh Medical Center, USA
| | - Julie M Donohue
- Department of Health Policy and Management, University of Pittsburgh Graduate School of Public Health, 130 DeSoto Street, Crabtree Hall A613, Pittsburgh, PA 15261, USA.
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Hodgkin D, Merrick EL, O'Brien PL, McGuire TG, Lee S, Deckersbach T, Nierenberg AA. Testing for clinical inertia in medication treatment of bipolar disorder. J Affect Disord 2016; 205:13-19. [PMID: 27391267 PMCID: PMC5048514 DOI: 10.1016/j.jad.2016.03.073] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2015] [Revised: 02/19/2016] [Accepted: 03/12/2016] [Indexed: 02/04/2023]
Abstract
BACKGROUND Clinical inertia has been defined as lack of change in medication treatment at visits where a medication adjustment appears to be indicated. This paper seeks to identify the extent of clinical inertia in medication treatment of bipolar disorder. A second goal is to identify patient characteristics that predict this treatment pattern. METHOD Data describe 23,406 visits made by 1815 patients treated for bipolar disorder during the STEP-BD practical clinical trial. Visits were classified in terms of whether a medication adjustment appears to be indicated, and also whether or not one occurred. Multivariable regression analyses were conducted to find which patient characteristics were predictive of whether adjustment occurred. RESULTS 36% of visits showed at least 1 indication for adjustment. The most common indications were non-response to medication, side effects, and start of a new illness episode. Among visits with an indication for adjustment, no adjustment occurred 19% of the time, which may be suggestive of clinical inertia. In multivariable models, presence of any indication for medication adjustment was a predictor of receiving one (OR=1.125, 95% CI =1.015, 1.246), although not as strong as clinical status measures. LIMITATIONS The associations observed are not necessarily causal, given the study design. The data also lack information about physician-patient communication. CONCLUSIONS Many patients remained on the same medication regimen despite indications of side effects or non-response to treatment. Although lack of adjustment does not necessarily reflect clinical inertia in all cases, the reasons for this treatment pattern merit further examination.
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Affiliation(s)
- Dominic Hodgkin
- Institute for Behavioral Health, Heller School for Social Policy and Management, Brandeis University, United States.
| | - Elizabeth L Merrick
- Institute for Behavioral Health, Heller School for Social Policy and Management, Brandeis University, United States
| | | | - Thomas G McGuire
- Department of Health Care Policy, Harvard Medical School, United States
| | - Sue Lee
- Institute for Behavioral Health, Heller School for Social Policy and Management, Brandeis University, United States
| | - Thilo Deckersbach
- Department of Psychiatry, Harvard Medical School, and Bipolar Clinic and Research Program, Massachusetts General Hospital, United States
| | - Andrew A Nierenberg
- Department of Psychiatry, Harvard Medical School, and Bipolar Clinic and Research Program, Massachusetts General Hospital, United States
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Asaad T, Okasha T, Ramy H, Fekry M, Zaki N, Azzam H, Rabie MA, Elghoneimy S, Sultan M, Hamed H, Refaat O, Shorab I, Elhabiby M, Elgweily T, ElShinnawy H, Nasr M, Fathy H, Meguid MA, Nader D, Elserafi D, Enaba D, Ibrahim D, Elmissiry M, Mohsen N, Ahmed S. Correlates of psychiatric co-morbidity in a sample of Egyptian patients with bipolar disorder. J Affect Disord 2014; 166:347-52. [PMID: 24981131 DOI: 10.1016/j.jad.2014.04.050] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2014] [Accepted: 04/25/2014] [Indexed: 01/12/2023]
Abstract
BACKGROUND AND OBJECTIVES Bipolar disorder (BD) is a complex, chronic mood disorder involving repeated episodes of depression and mania/hypomania. Two thirds of patients with bipolar disorder have a comorbid psychiatric condition. This study aims to assess the prevalence of Axis I diagnosis with its socio-demographic and clinical correlates among a sample of Egyptian patients with bipolar disorder. METHODS Out of the 400 patients who were enrolled in the study from number of governmental and private psychiatric hospitals in Cairo, Egypt, 350 patients diagnosed with bipolar affective disorders (157 females and 193 males) with age ranging from 18 to 55years were selected. Patients were assessed using the Structured Clinical Interview for DSM-IV Axis I disorder (Research Version) (SCID-I). RESULTS Prevalence of psychiatric comorbidity among BD patients was 20.3% (71 patients) among which 63 patients (18%) had comorbid substance abuse and 8 patients (2.3%) had comorbid anxiety disorders. LIMITATIONS The study was limited by its cross sectional design with some patients having florid symptoms during assessment, not having a well representative community sample. This might have decreased the reliability and prevalence of lifetime psychiatric comorbidity due to uncooperativeness or memory bias. The study group was composed of bipolar patients attending tertiary care service which limits the possibility of generalizing these results on different treatment settings. CONCLUSIONS Substance abuse followed by anxiety disorders was found to be the most common psychiatric comorbidity. Family history of psychiatric disorders and substance abuse as well as current psychotic features were highly correlated with comorbidity.
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Affiliation(s)
- Tarek Asaad
- Institute of Psychiatry, Ain Shams University, PO Box: 11657, Cairo, Egypt
| | - Tarek Okasha
- Institute of Psychiatry, Ain Shams University, PO Box: 11657, Cairo, Egypt
| | - Hisham Ramy
- Institute of Psychiatry, Ain Shams University, PO Box: 11657, Cairo, Egypt
| | - Mohamed Fekry
- Institute of Psychiatry, Ain Shams University, PO Box: 11657, Cairo, Egypt
| | - Nivert Zaki
- Institute of Psychiatry, Ain Shams University, PO Box: 11657, Cairo, Egypt
| | - Hanan Azzam
- Institute of Psychiatry, Ain Shams University, PO Box: 11657, Cairo, Egypt
| | | | - Soheir Elghoneimy
- Institute of Psychiatry, Ain Shams University, PO Box: 11657, Cairo, Egypt
| | - Marwa Sultan
- Institute of Psychiatry, Ain Shams University, PO Box: 11657, Cairo, Egypt
| | - Hani Hamed
- Institute of Psychiatry, Cairo University, Egypt
| | - Osama Refaat
- Institute of Psychiatry, Cairo University, Egypt
| | - Iman Shorab
- Institute of Psychiatry, Ain Shams University, PO Box: 11657, Cairo, Egypt
| | - Mahmoud Elhabiby
- Institute of Psychiatry, Ain Shams University, PO Box: 11657, Cairo, Egypt
| | | | | | - Mohamed Nasr
- Institute of Psychiatry, Cairo University, Egypt
| | - Heba Fathy
- Institute of Psychiatry, Cairo University, Egypt
| | - Marwa A Meguid
- Institute of Psychiatry, Ain Shams University, PO Box: 11657, Cairo, Egypt
| | - Doaa Nader
- Institute of Psychiatry, Ain Shams University, PO Box: 11657, Cairo, Egypt
| | - Doha Elserafi
- Institute of Psychiatry, Ain Shams University, PO Box: 11657, Cairo, Egypt
| | - Dalia Enaba
- Institute of Psychiatry, Cairo University, Egypt
| | - Dina Ibrahim
- Institute of Psychiatry, Ain Shams University, PO Box: 11657, Cairo, Egypt
| | - Marwa Elmissiry
- Institute of Psychiatry, Ain Shams University, PO Box: 11657, Cairo, Egypt
| | - Nesreen Mohsen
- Institute of Psychiatry, Ain Shams University, PO Box: 11657, Cairo, Egypt
| | - Sherin Ahmed
- Institute of Psychiatry, Ain Shams University, PO Box: 11657, Cairo, Egypt
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Donohue J, O'Malley AJ, Horvitz-Lennon M, Taub AL, Berndt ER, Huskamp HA. Changes in physician antipsychotic prescribing preferences, 2002-2007. Psychiatr Serv 2014; 65:315-22. [PMID: 24337224 PMCID: PMC3947600 DOI: 10.1176/appi.ps.201200536] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Physician antipsychotic prescribing behavior may be influenced by comparative effectiveness evidence, regulatory warnings, and formulary and other restrictions on these drugs. This study measured changes in the degree to which physicians are able to customize treatment choices and changes in physician preferences for specific agents after these events. METHODS The study used 2002-2007 prescribing data from the IMS Health Xponent database and data on physician characteristics from the American Medical Association for a longitudinal cohort of 7,399 physicians. Descriptive and multivariable regression analyses were conducted of the concentration of prescribing (physician-level Herfindahl index) and preferences for and likelihood of prescribing two first-generation antipsychotics and six second-generation antipsychotics. Analyses adjusted for prescribing volume, specialty, demographic characteristics, practice setting, and education. RESULTS Antipsychotic prescribing was highly concentrated at the physician level, with a mean unadjusted Herfindahl index of .33 in 2002 and .29 in 2007. Psychiatrists reduced the concentration of their prescribing more over time than did other physicians. High-volume psychiatrists had a Herfindahl index that was half that of low-volume physicians in other specialties (.18 versus .36), a difference that remained significant (p<.001) after adjustment for physician characteristics. The share of physicians preferring olanzapine dropped from 29.9% in 2002 to 10.3% in 2007 (p<.001) while the share favoring quetiapine increased from 9.4% to 44.5% (p<.001). Few physicians (<5%) preferred a first-generation antipsychotic in 2002 or 2007. CONCLUSIONS Preferences for specific antipsychotics changed dramatically during this period. Although physician prescribing remained heavily concentrated, the concentration decreased over time, particularly among psychiatrists.
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Huskamp HA, O'Malley AJ, Horvitz-Lennon M, Taub AL, Berndt ER, Donohue JM. How quickly do physicians adopt new drugs? The case of second-generation antipsychotics. Psychiatr Serv 2013; 64:324-30. [PMID: 23280376 PMCID: PMC3907700 DOI: 10.1176/appi.ps.201200186] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
OBJECTIVE The authors examined physician adoption of second-generation antipsychotic medications and identified physician-level factors associated with early adoption. METHODS The authors estimated Cox proportional-hazards models of time to adoption of nine second-generation antipsychotics by 30,369 physicians who prescribed antipsychotics between 1996 and 2008, when the drugs were first introduced, and analyzed the total number of agents prescribed during that time. The models were adjusted for physicians' specialty, demographic characteristics, education and training, practice setting, and prescribing volume. Data were from IMS Xponent, which captures over 70% of all prescriptions filled in the United States, and the American Medical Association Physician Masterfile. RESULTS On average, physicians waited two or more years before prescribing new second-generation antipsychotics, but there was substantial heterogeneity across products in time to adoption. General practitioners were much slower than psychiatrists to adopt second-generation antipsychotics (hazard ratios (HRs) range .10-.35), and solo practitioners were slower than group practitioners to adopt most products (HR range .77-.89). Physicians with the highest antipsychotic-prescribing volume adopted second-generation antipsychotics much faster than physicians with the lowest volume (HR range .15-.39). Psychiatrists tended to prescribe a broader set of antipsychotics (median=6) than general practitioners and neurologists (median=2) and pediatricians (median=1). CONCLUSIONS As policy makers search for ways to control rapid health spending growth, understanding the factors that influence physician adoption of new medications will be crucial in the efforts to maximize the value of care received by individuals with mental disorders as well as to improve medication safety.
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Affiliation(s)
- Haiden A Huskamp
- Department of Health Care Policy, Harvard Medical School, 180 Longwood Ave., Boston, MA 02115, USA.
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