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

Abstract

Background Several national initiatives aim to teach high-value care to residents. While there is a growing body of literature on cost impact of physicians' therapeutic decisions, few studies have assessed factors that influence residents' prescribing practices. Objective We studied factors associated with intensive health care utilization among internal medicine residents, using brand name statin prescribing as a proxy for higher-cost care. Methods We conducted a retrospective, cross-sectional analysis of statin prescriptions by residents at an urban academic internal medicine program, using electronic health record data between July 1, 2010, and June 30, 2011. Results For 319 encounters by 90 residents, patients were given a brand name statin in 50% of cases. When categorized into quintiles, the bottom quintile of residents prescribed brand name statins in 2% of encounters, while the top quintile prescribed brand name statins in 98% of encounters. After adjusting for potential confounders, including patient characteristics and supervising attending, being in the primary care track was associated with lower odds (odds ratio [OR], 0.38; P = .02; 95% confidence interval [CI], 0.16–0.86), and graduating from a medical school with an above-average hospital care intensity index was associated with higher odds of prescribing brand name statins (OR, 1.70; P = .049; 95% CI, 1.003–2.88). Conclusions We found considerable variation in brand name statin prescribing by residents. Medical school attended and residency program type were associated with resident prescribing behavior. Future interventions should raise awareness of these patterns in an effort to teach high-value, cost-conscious care to all residents.

Effect of Attending Practice Style on Generic Medication Prescribing by Residents in the Clinic Setting: An Observational Study

“…A prior study found that the medical school care intensity environment influenced resident prescribing of generic medications. 12 Furthermore, although we aimed to study an aspect of physician behavior related to costeffective care, our findings may represent a more general relationship between attending and resident practice styles across other practice behaviors not related to cost. Availability of databases containing residency program scheduling, faculty, and resident characteristics and practice patterns would enable researchers to identify specific factors that influence these and other practice behaviors.…”

“…11 In the ambulatory setting, a study of resident prescribing practices found considerable variation in generic vs. brand-name statin prescribing by residents after controlling for the effect of the supervising attending. 12 After completing training, less experienced physicians had higher overall cost profiles than more experienced physicians. 13 Although these findings suggest that residents do not perfectly mirror their attending physicians' practice patterns, the relationship between attending physicians and the practice of residents that they supervise has not been studied directly.…”

“…A few studies have documented the impact of residents on care decisions and variation in practice styles across residents. [10][11][12][13] In the inpatient setting, residents have been found to independently account for a considerable proportion of variation in hospital length of stay and ancillary resource use, 10 including the ordering of laboratory tests. 11 In the ambulatory setting, a study of resident prescribing practices found considerable variation in generic vs. brand-name statin prescribing by residents after controlling for the effect of the supervising attending.…”

Should Physicians be Encouraged to use Generic Names and to Prescribe Generic Drugs?

“…A recent study showed that the residents at all levels are likely to prescribe the expensive statin medications even when the generic versions are visible. 1 There is also some evidence that junior physicians have higher cost profiles than physicians with greater experience. 2 In 2008, Kesselheim et al 3 showed that despite paucity of evidence that brand drugs are superior to the generic formulations, editorialists frequently raise concerns regarding the efficacy of generic drugs and advocate against the interchangeability.…”

Teaching Wisely

“…In this issue of the Journal of Graduate Medical Education, Ryskina et al 14 begin to explore the connections among various training factors and the propensity for brand name statin prescribing. They conclude that residents at a single urban academic residency clinic prescribe brand name statins at highly variable rates: when residents were categorized into quintiles by rate of brand name statin prescribing, the bottom quintile prescribed brand name statins in 1.7% of encounters and the top quintile in 98.2% of encounters.…”