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Executive Summary

Adverse reactions to Rx drugs are under-reported, and a better understanding of drug effects in the elderly will require better physician-patient communication, according to a study reported to a PMA-sponsored conference on Feb. 13. Johns Hopkins University researchers Pearl German, ScD, and Lawrence Klein, MD, said their study of drug experience in the elderly suggests that physicians do not know the extent of adverse reactions caused by the drugs they prescribe because elderly patients are less likely to perceive symptoms as drug side effects. Reviewing elderly patients who received drug regimens, clinicians in the study determined that 250 symptoms were highly likely to be caused by the drugs, but only 37.2% of the patients reported the symptoms as adverse reactions to their physicians, German said. Patients in the study were asked the extent to which their physicians counseled them with regard to their drug therapies. The researchers found that 25.4% of the patients indicated their physicians did not explain what the drug was supposed to do; 91.6% indicated their physicians did not discuss how the drug might "bother" them; 47.1% indicated their physicians did not ask how the drug "helped" or "bothered" them after the regimen was started; and 87.7% indicated that the drug was not changed after discussing with their physicians how the drug was helping or bothering them. German suggested in her summary that nonlife-threatening effects of drugs, because they are frequently not discussed, may be more insidious than imagined and lead to isolation, depression, and an otherwise detrimental outcome. Vanderbilt University Pharmacoepidemiology Div. Director Wayne Ray, PhD, contended that "another challenge" as important as development of newer and better drugs is assuring that "existing pharmaceuticals are prescribed in a safe and cost-effective manner." Ray maintained that one method for improving prescribing patterns is the "educational visit" to doctors. "The educational visit which targets those who use the drugs in question is a method that can improve prescribing while maintaining both the dignity of the practicing physician as well as the safety of the patient," he said. In a study sponsored in conjunction with the Tennessee Medical Assn. and the state Medicaid program, Ray said MDs visited practitioners across the state to find whether intervention was worth the dollar cost. The study used the Medicaid program's database and focused on oral cephalo-sporins. "In certain clinical circumstances other less expensive drugs, as compared to cephalosporins, are equally safe and efficacious," he explained. During their educational visits, Ray said, practitioners were asked to "save the cephalosporins for when you really need them; when a cheaper antibiotic will do, please use it." The results of the study showed that for "the doctors who were visited by another doctor, there was about a 25% reduction in oral cephalosporin use when compared to the control," Ray reported. "This resulted in a cost reduction of about $950 per visit." In addition, he said, "the program was received very well." The physicians in practice praised the educational program and urged that it be continued for other drugs. The Tennessee study data has been previously submitted at a House Subcmte. hearing on the use of antibiotics ("The Pink Sheet" Dec. 24, 1984, p. 16). Bristol-Myers Vice Chairman William Miller described possible pharmaceutical/medical innovations in the 21st Century. In prepared remarks submitted to the conference and summarized by PMA President Mossinghoff, Miller wrote that many "medical advances to eradicate or at least minimize the debilitating illnesses of old age . . . in the year 2000 and beyond are already in the test-tube stage." Miller said future regimens will include gene replacement therapy, memory and cognition-enhancing drugs, bionics, organ transplants, body part replacements, immune system stimulants, monoclonal antibody therapy, and a "deluge of self-diagnostic kits." Among the devices the envisioned for the next century are monitors that will be worn on the wrist and "incorporate a microprocessor and reservoirs of medicine with electronic probes. Such devices will be able to sense changes in our bodies -- measuring vital signs, analyzing blood and enzyme levels, and, when necessary, actually administering drugs in carefully programmed amounts." Mt. Sinai School of Medicine Professor Leslie Libow, MD, maintained that physician education "needs to be sharpened with regard to reducing the number of simultaneous medications given to the elderly," and that the community pharmacist should be utilized as a "detector of excess medications and of likely hazardous interactions." Libow also contended that "bladder selective" medications to correct urinary incontinence must be developed, "similar to the development of relatively cardio-selective medications" among beta blockers. "This challenge can be met by the pharmaceutical industry," he added. "Urinary incontinence is one of the big secrets of late life," Libow explained. "It is found in approximately 30% of community-residing elderly, 30-50% of hospitalized elderly, and 60% of those in nursing homes." Current drug therapies, which include anticholinergics, cholinergics, and alpha adrenergics, "are moderately effective for the incontinence but also often adversely affect the brain and cardiovascular system," he said. Ongoing research into bladder function uses "'urodynamic' measurements of bladder and sphincters," Libow continued. "These safe, painless procedures are revealing insights into new classifications, etiologies, and treatments." American Assn. for Retired Persons Exec Director Cyril Brickfield contended that recent price hikes and antigeneric campaigns by the brandname drug industry is eroding the trust between elderly patients and their prescribers and pharmacists. "Until now older Americans have been reluctant to adopt the attitude of 'let the buyer beware,' especially when it comes to medicine and health. They have tended to rely on their doctors and pharmacists without question," Brickfield said. "But I can assure you that this trust is being jeopardized by this continued inflated pricing structure of the drug industry," he said, noting that drug prices have risen since 1981 by 56%, compared to 23% for the Consumer Price Index over the same period.

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