Who Is Responsible for Inappropriate Drug Use

Although it can be debated how big the problem really is, inappropriate or unnecessary care is delivered with some frequency.  In the case of prescription drugs, inappropriate prescribing could be due in part to patients pushing doctors for medications they have read about or seen an ad for, and it could be due in part to physicians prescribing drugs for patients in circumstances when the drug’s use is questionable.  Doctors could in turn be driven by manufacturer advertising and marketing efforts.  A new study, from the West African nation of Mali and published by the National Bureau of Economic Research, attempts to disentangle these two effects.   (NBER Paper)   The theory behind physicians’ ability to over-prescribe is the traditional one that they are “experts” on whose judgment the average patient-consumer must rely, so doctors can push over use.  In reality, many doctors may lack good knowledge about when it is best to use a particular treatment.  And even in poorer countries there are often networks of information, accurate or inaccurate, about various medical therapies, including drugs.  The study focussed on patients treated for malaria, for which there are very clear guidelines about when and which type of drug therapy should be used.  Historically in Mali, a large number of patients who don’t have malaria have still gotten a drug treatment and many of those who do have the disease have gotten the wrong drug therapy, typically for severe malaria when they had an uncomplicated condition.

The researchers did a study in which sometimes discount coupons were available for simple malaria drugs, sometimes both the patient and doctor knew of the coupons, and sometimes only the doctor and on some days, no coupon was available.  If doctors were worried about being pressured by patients for a drug, on days when only they knew about the coupons, they could not tell the patients about them.  The results suggest that in fact doctors prescribe more when patients are aware of the coupon, and presumably exert more pressure to get the drug.  And almost all of the excess prescribing is driven by patients with very low-level disease, suggesting that patient pressure, based on knowledge about availability of the free medications, is leading doctors to take the path of least resistance.  There was no evidence supporting the possibility that doctors sought to increase revenue for themselves by up-selling medications.   While this study was done in a low-income developing nation, to some extent human economic behavior seems to be fairly universal, and not significantly driven by cultural differences.  And there is other research, even in the US, suggesting that physicians are influenced by patient requests or demands for treatment.  The practical implications of this research are that attempts to ensure less inappropriate care use may need to be more aimed at patients than providers.