Off-label use common, not always backed by data
More than 20% of the prescriptions written for the 500 most commonly prescribed drugs in 2001 were for off-label uses, and almost three-quarters of those uses had no scientific support for the use, according to a survey of office-based physicians.
Researchers found that while most prescriptions are written for the use indicated by the Food and Drug Administration (FDA), one-fifth were for off-label uses. While some off-label use logically followed the indications for use, such as the use of asthma medications for other lung ailments, some uses lacked data to back them up — for example, the use of anticonvulsants to treat chronic pain.
The study, conducted by David C. Radley, MPH, Dartmouth Medical School, appears in Archives of Internal Medicine ("Off-label prescribing by office-based physicians," 2006; 166:1,021-1,026), raises questions about patient safety and health care costs, the authors conclude, since off-label uses do not receive the same level of scientific scrutiny as approved uses. Cardiac medications (46%), anticonvulsants (46%), and medications used to treat asthma (42%) were the most likely to be prescribed off-label. Psychiatric drugs were highly likely to be prescribed off-label with limited or no scientific support (96% vs. 4% strong support), as were allergy medications (89% vs. 11% strong support).
Radley and his colleagues surveyed 3,500 physicians quarterly for one year, during which time the doctors reported on all patient interactions during two consecutive workdays. Diagnoses and prescriptions were indexed, and prescriptions were compared to the indications listed on the drug's package insert. Off-label prescriptions were further evaluated and classified as having strong scientific support if evidence from drug trials or clinical settings suggested the medication was effective for the condition it was prescribed to treat, or as having limited to no scientific support if such evidence did not exist.
Study says fewer doctors providing charity care
Ten years ago, 76% of physicians in the United States reported providing charity care to the uninsured, but that figure has declined every year, with the latest figures, from 2004-2005, showing 68% of physicians donating their time and skill to charity medical care. The center for Studying Health System Change reports each year on charity care, and in its most recent report states that declines in charity care have been seen across most major specialties, practice types, practice income levels, and geographic regions.
Increasing financial pressures and changes in practice arrangements may account in part for the continuing decrease in physician charity care, the center's researchers conclude. Physicians at the highest income levels continue to report the greatest provision of charity care, with 75.6% of physicians with practice incomes greater than $250,000 providing charity care in 2004-05, compared with 66.4% of physicians earning less than $120,000. The drop in physician charity care occurred as the number of uninsured Americans grew to 45.5 million in 2004, signaling growing stress on the health care safety net, according to a spokesman for the Center.
The Center for Studying Health System Change report is available at www.hschange.org/CONTENT/826/?topic=topic02.
EDs report greater shortage on-call specialist coverage
Nearly three-quarters of emergency department medical directors reported inadequate on-call specialist coverage in 2005, leaving patients at risk of not getting the orthopedic, plastic surgery, neurosurgery, otolaryngology, and hand surgery care they need in an emergency.
The Irving, TX-based American College of Emergency Physicians (ACEP) reports the shortage is up from two-thirds of ED medical directors surveyed by ACEP in 2004. The share of hospitals paying stipends for on-call specialist coverage increased to 36% in 2005.
ACEP said the survey findings are evidence of further strain on an already frayed health care system, driven by reduced health insurance coverage and funding and ongoing medical liability concerns.
According to the study's authors, the Emergency Medical Treatment and Active Labor Act (EMTALA) created "an unfunded safety net program for everyone using the nation's emergency departments," fueling a demand for emergency care that increases by 5 million visits each year while capacity decreases.