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

Abstract

BACKGROUND: Despite increased emphasis on costconsciousness in graduate medical training, there is little empirical evidence of the role of attending physician supervision on resident practice in this area. OBJECTIVE: To study whether the prescribing practices of attendings influence residents' prescribing of brand-name statin medications in the ambulatory clinic setting. DESIGN AND PARTICIPANTS: A retrospective study of statin prescriptions by residents at two internal medicine residency programs, using electronic medical record data from July 2007 through November 2011. MAIN MEASURES: We estimated multivariable hierarchical logistic regression models to assess the independent effect of the supervising attending's rate of brand-name prescribing in the preceding quarter on the likelihood of a resident prescribing a brand-name statin. KEY RESULTS: The sample included 342 residents and 58 attendings, accounting for 10,151 initial statin prescriptions, including 3,942 by residents. Brand-name statins were prescribed in about onefourth of encounters. After adjusting for patient-, physician-, and practice-level factors, the supervising attendings' brand-name prescribing rate in the quarter preceding the encounter was positively associated with a postgraduate year (PGY)-1 resident's prescribing a brand-name statin, but not for PGY-2 or PGY-3 residents. For PGY-1 residents, the adjusted probability of a resident prescribing a brand-name statin ranged from 22.6 % (95 % CI 17.3-28.0 %, p < 0.001) for residents supervised by an attending who prescribed < 20 % brand-name statins in the previous quarter to 41.6 % (95 % CI 24.6-58.5 %, p < 0.001) for residents supervised by an attending who prescribed at least 80 % brand-name statins in the previous quarter. A higher PGY level was associated with brand-name prescribing (aOR 2.07, 95 % CI 1.28-3.35, p = 0.003 for PGY-2; aOR 2.15, 95 % CI 1.31-3.55, p = 0.003 for PGY-3, vs. PGY-1). CONCLUSIONS: Supervising attendings' prescribing of brand-name medications may have a significant influence on PGY-1 residents' prescribing of brand-name medications, but not on prescribing by more senior residents.

Effect of Social Comparison Feedback on Laboratory Test Ordering for Hospitalized Patients: A Randomized Controlled Trial

“…Evidence suggests that factors that influence physician test-ordering behaviors range broadly beyond physician knowledge and local Estimates reported from six models: (1) intent-to-treat (two arms) comparing control vs. intervention, (2) post-hoc model (two arms) comparing intervention vs. control by day post intervention, (3) post-hoc model (three arms) comparing controls vs. physicians randomized to the intervention who opened the intervention e-mail vs. those who did not open the intervention e-mail, (4) post-hoc model (three arms) comparing controls vs. physicians randomized to the intervention who accessed the dashboard vs. those who did not access the dashboard, and (5) secondary outcome: controls vs. intervention for laboratory orders not targeted by the intervention p-value <0.05 practice patterns. 10,[27][28][29] Residents may be reluctant to reduce ordering because of perceived institutional or attending expectations, risk-aversion, and uncertainty about potential harms (e.g., lack of cost transparency). 14,30 Interventions that aim to influence physician behavior should be thoroughly tested prior to broad implementation to avoid unanticipated effects, particularly in areas of practice with high clinical uncertainty.…”

Residents' self‐report on why they order perceived unnecessary inpatient laboratory tests

“…Hospitalists at academic medical centers face growing pressures to develop processes to reduce low‐value care and train residents to be stewards of healthcare resources . Studies have described that institutional and training factors drive residents' resource utilization patterns, but, to our knowledge, none have described what factors contribute to residents' unnecessary laboratory testing. To better understand the factors associated with residents' ordering patterns, we conducted a qualitative analysis of internal medicine (IM) and general surgery (GS) residents at a large academic medical center in order to describe residents' perception of the: (1) frequency of ordering unnecessary inpatient laboratory tests, (2) factors contributing to that behavior, and (3) potential interventions to change it.…”

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

“…A study suggested that the post graduate year 1 (PGY1) residents prescribe brand name statins in a manner that reflects their attending physicians, whereas the senior residents prescribe higher cost drugs regardless of the attending practices. 11 This suggests that there is a need to educate across the board. Restricting ourselves to the medical names can also help limit the conflicts of interests the physicians have with the industry.…”