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Executive Summary

The use of part-time senior members of the local medical community in Tennessee to advise MDs on antibiotic use is showing a lasting effect on prescribing practices in that state, Vanderbilt University Preventive Medicine Chairman William Schaffner, MD, told a House hearing on Dec. 19. Schaffner, who arranged a "prescribing improvement" project in 1980 under the auspices of several Tennessee medical societies, told the Hill hearing that the "beneficial effect" of visits by physician counselors "persisted through the second year after the educational intervention." He maintained that the staying power of the prescribing advice was "a striking result, considering the brevity of the educational visit (less than 15 minutes)." The Tennessee project indicates, Schaffner told the hearing, "that doctors in practice are eager for information which is presented in an unbiased and helpful fashion which will aid them in the appropriate use of antibiotics." Schaffner concluded that the use of physicians to convey the prescribing information was crucial to the effectiveness of the program. "In our study," he said, "the 'messenger' was more important than the message." Schaffner's appearance at the Dec. 19 hearing is the second Hill publicity for private sector prescribing education programs within the last two years. In June 1983, a Harvard group reported to a joint House/Senate hearing on a program of counter-detailing and "un-advertisements" ("The Pink Sheet" July 4, 1983, page 6). The Dec. 19 hearing was held by Science & Technology Oversight Subcmte. and was chaired by Rep. Gore from Schaffner's home state of Tennessee. Prescribing Habit Changes Last A Year; Rxs For Contraindicated Antibiotics Dropped 25% Schaffner's initial study of a physician prescribing information campaign was reported in JAMA in the second half of 1983. The Tennessee study showed cuts in out-patient Rxs for oral cephalosporins of about 25% from the counter-detailing activities ("The Pink Sheet" July 25, 1983, T&G-3). A follow-up report on the continued effects of the Tennessee program has been accepted for publication in an upcoming JAMA issue. Schaffner told the Gore hearing that "the brief visits by the physician counselors were remarkably successful in reducing the prescribing of both the contraindicated antibiotics and the oral cephalosporins during only a single visit." The two "contraindicated" antibiotics in the study were chloramphenicol and clindamycin. "For the contraindicated antibiotics," Schaffner said, "the reduction in prescribing which would be attributable to the physician counselor visits was 34% in the average number of prescriptions written per doctor. Also, the proportion of doctors prescribing these medications at all was reduced by 18% and the average number of prescriptions written per doctor through the year was reduced by approximately half." The prescribing changes effected by the face-to-face peer visits "lasted throughout the initial year of evaluation," Schaffner told the Gore hearing. "Doctors, when visited by the physician counselors responded equally well to the message of improved patient care as well as reducing excessive costs," Schaffner contended. "And when they 'get the message,' and change their behavior, the effect lasts a long time." The Vanderbilt professor declared: "Indeed, I am unaware of any other brief, educational encounter, or any other subject that has been as effective in changing anyone's behavior as was this 15 minute visit of a doctor in private practice by physician counselors representing their professional organizations." He maintained: "This study demonstrates that a non-punitive, educational program sponsored by the medical profession can change patterns of office practice that are inappropriate or excessively costly." In prepared testimony for the Gore hearing, Pharmaceutical Mfrs. Assn. (PMA) President Joseph Stetler and VP-Science & Technology John Jennings, MD, supported the concept of local efforts to encourage appropriate prescribing practices. The PMA testimony stated: "Those at the local level also have a major role to play -- which our companies will continue to support -- in controlling the spread of bacterial resistance." PMA said: "Clinicians must learn the mechanics of resistance, they must become more knowledgeable about appropriate prescribing practices and they must ensure that the use of antibiotics is closely monitored so that, when resistance begins to spread, it can be recognized early and different antibiotics can be prescribed." In an exchange with Gore, Stetler further commented that programs such as the Tennessee education effort show some effectiveness. Asked by Gore if PMA as an organization would consider funding some kind of educational program, Stetler pointed out that the assn. has a current budget shortfall and is not likely to take on new initiatives. Stetler noted that individual companies might be interested in those types of programs. Both the Harvard and Vanderbilt studies were funded by the Natl. Center for Health Services Research. However, the Harvard group reportedly has been in contact with drug companies for additional support. HRG Urges Govt. Sponsorship Of Counter-Ads To Reduce Misprescribing Stetler suggested a rifle approach to uncover MDs responsible for the major portion of misprescribing. Asked by Gore if that were a feasible approach, Schaffner agreed, calling it far and away the best approach. Gore urged that the project be expanded to a natl. scope. Schaffner replied that it might be possible to scale up the Tennessee program to test its effectiveness. The Health Research Group (HRG) urged further use of prescribing education in its prepared presentation to the Gore hearing. Citing the Vanderbilt and Harvard examples, HRG said: "There should be a significant expansion of cost effective efforts to reverse the drug company-induced misprescribing by many physicians by means of attractive counter-ads and, especially, by personal visits from doctors or pharmacists. HRG called for additional govt. sponsorship of such programs. In addition to supporting further education about appropriate prescribing practices, PMA pointed out in its testimony that continuing developments from antibiotic research aid in containing resistant strains. Referring to Beecham's recent Augmentin (amoxicillin/clavulanate) approval, PMA noted "an older antibiotic was given new efficacy against resistant pathogens when a decoy molecule was added to the compound." Without reference to the brandname or company, PMA pointed out that Beecham has a ticarcillin/clavulanate compound pending approval at FDA. "The decoy agent could be used to enhance the effectiveness of a wide variety of other penicillins and cephalosporins," the assn. said. PMA declared: "The pharmaceutical industry is confident it can continue to develop products that will help to curb the spread of bacterial resistance. Drug companies are engaged in basic research on the mechanics of such resistance, and some of our companies are developing new antimicrobials that will be less likely to induce resistance."

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