Regulating Off-Label Promotion - A Critical Test

Distinguishing moral hazard from access for high-cost healthcare under insurance

CONTEXT

Health policy has long been preoccupied with the problem that health insurance stimulates spending ("moral hazard"). However, much health spending is costly healthcare that uninsured individuals could not otherwise access. Field studies comparing those with more or less insurance cannot disaggregate moral hazard versus access. Moreover, studies of patients consuming routine low-dollar healthcare are not informative for the high-dollar healthcare that drives most of aggregate healthcare spending in the United States.

METHODS

We test indemnities as an alternative theory-driven counterfactual. Such conditional cash transfers would maintain an opportunity cost for patients, unlike standard insurance, but also guarantee access to the care. Since indemnities do not exist in U.S. healthcare, we fielded two blinded vignette-based survey experiments with 3,000 respondents, randomized to eight clinical vignettes and three insurance types. Our replication uses a population that is weighted to national demographics on three dimensions.

FINDINGS

Most or all of the spending due to insurance would occur even under an indemnity. The waste attributable to moral hazard is undetectable.

CONCLUSIONS

For high-cost care, policymakers should be more concerned about the foregone efficient spending for those lacking full insurance, rather than the wasteful spending that occurs with full insurance.

Randomized Study of Providing Evidence Context to Mitigate Physician Misinterpretation Arising From Off-Label Drug Promotion

Background:

Recent court decisions have thrown into question the Food and Drug Administration’s rules limiting manufacturer promotion of prescription drugs for unapproved uses. We assessed how providing pro forma disclosures or more descriptive evidence context about the data supporting an off-label claim affected physicians’ beliefs about drug efficacy.

Methods and Results:

In online and mailed surveys, we randomized national samples of board-certified, clinically active cardiologists, internists, and endocrinologists to receive 1 of 3 information scenarios about a hypothetical drug derived verbatim from excerpts on the website for Vascepa, a prescription fish oil for which Food and Drug Administration specially permitted off-label promotion after a manufacturer lawsuit. The scenarios presented information about the approved on-label indication (severe hypertriglyceridemia), off-label claim + pro forma disclaimers (suggestive but not conclusive evidence for use as an add-on to a statin for patients reaching low-density lipoprotein goal but with persistent moderate hypertriglyceridemia), and off-label claim + evidence context (eg, reports on 3 trials failing to demonstrate cardiovascular benefit of other triglyceride-lowering drugs for such patients). Among 686 respondents (48% response rate), 29% reported receiving off-label information about Vascepa (ie, use as an add-on to a statin) from the manufacturer, and 16% had prescribed it off-label for this purpose. Off-label prescribing was 5 times higher among physicians who received such off-label information (38% versus 7%, P <0.001). For the hypothetical drug, the proportion of physicians endorsing the unproven claim that the drug reduced cardiovascular risk was similar among those randomized to the on-label and off-label claim + pro forma disclaimers scenarios (35% versus 37% [95% CI, −6% to 11%]), but substantially lower among those randomized to the off-label claim + evidence context scenario (21% [95% CI, −24% to 7%]).

Conclusions:

Physicians who received company information about the unapproved use of Vascepa were more likely to report prescribing it off-label. Supplementing off-label claims with evidence context improved the prescribers’ knowledge and reduced enthusiasm for the unproven, off-label indication of reducing cardiovascular risk.

Aerosolized Vasodilators for the Treatment of Pulmonary Hypertension in Cardiac Surgical Patients: A Systematic Review and Meta-analysis

BACKGROUND

In cardiac surgery, pulmonary hypertension is an important prognostic factor for which several treatments have been suggested over time. In this systematic review and meta-analysis, we compared the efficacy of inhaled aerosolized vasodilators to intravenously administered agents and to placebo in the treatment of pulmonary hypertension during cardiac surgery. We searched MEDLINE, CENTRAL, EMBASE, Web of Science, and clinicaltrials.gov databases from inception to October 2015. The incidence of mortality was assessed as the primary outcome. Secondary outcomes included length of stay in hospital and in the intensive care unit, and evaluation of the hemodynamic profile.

METHODS

Of the 2897 citations identified, 10 studies were included comprising a total of 434 patients.

RESULTS

Inhaled aerosolized agents were associated with a significant decrease in pulmonary vascular resistance (-41.36 dyne·s/cm, P= .03) and a significant increase in mean arterial pressure (8.24 mm Hg, P= .02) and right ventricular ejection fraction (7.29%, P< .0001) when compared to intravenously administered agents. No significant hemodynamically meaningful differences were observed between inhaled agents and placebo; however, an increase in length of stay in the intensive care unit was shown with the use of inhaled aerosolized agents (0.66 days, P= .01). No other differences were observed for either comparison.

CONCLUSIONS

The administration of inhaled aerosolized vasodilators for the treatment of pulmonary hypertension during cardiac surgery is associated with improved right ventricular performance when compared to intravenously administered agents. This review does not support any benefit compared to placebo on major outcomes. Further investigation is warranted in this area of research and should focus on clinically significant outcomes.