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PA attitudes toward prescribing medications

Eric Vangsnes, MS, PA-C

The author is an assistant professor in the physician assistant program at Western Michigan University College of Health and Human Services, Kalamazoo, Mich. He has indicated no relationships to disclose relating to the content of this article.

Elderly persons comprise only 13% of the United States population, yet they account for one third of all prescription drugs used.¹ The Kaiser Family Foundation reports that in a 2003 survey of 17,685 Medicare-eligible older persons, respondents with three or more chronic conditions take five or more medications regularly (73%).²

Before the initiation of Part D, many relied on Medicare as their sole medical insurance. Half of United States residents older than 65 years lack medical insurance for prescription drug coverage, even though 40% receive supplemental insurance from employers or have purchased a Medigap policy, and about 10% of Medicare recipients qualify for Medicaid prescription coverage.³ Medicare recipients may spend more than 10% of their income on prescription medications.⁴ Prescription medication costs can be so prohibitive that some people may be forced to choose between paying for housing, food, or utilities and buying their medication.⁵

Impact on adherence to treatment Medication costs can affect patient compliance. On the Kaiser Family Foundation survey, 26% of respondents reported not filling the prescription or not taking the medication as directed because of cost.² The Center on an Aging Society reported that many elderly persons, especially those with low incomes, took less medicine than was prescribed.⁶ Up to one quarter of people without drug coverage had not filled prescriptions at least once in the past year because of the cost, had skipped doses to make medication last longer, and had spent less in the past year on food and heat in order to purchase medications.⁵

Poorer health outcomes Patients who cannot afford to buy their medications or to take their medications as prescribed tend to have poorer health outcomes.^7-9 Shulman and colleagues found that 36.5% of adult patients with uncontrolled hypertension reported difficulty paying for their medications, compared with 15.5% of those whose BP was controlled.¹⁰ The study concluded that cost of prescription drugs contributed to inadequate control of hypertension in certain population subgroups.¹⁰

People are often hospitalized or admitted to nursing homes because of illnesses or sequelae resulting from lack of medicines.^7-9,11 The high cost of medication may ultimately lead to a greater number of hospital and nursing home admissions.^8,9,11,12 The ability of medical care providers to select cost-effective therapy is important not only for the patient but for other consumers as well.¹³

Knowledge of drug costs and clinician attitudes towards the use of generic over branded drugs can have a significant impact on the decision to choose a less expensive regimen over a more expensive one.^14,15 In a practical sense, deciding which medication to choose often depends on the provider’s knowledge about drug safety and efficacy, beliefs about patient compliance, and attitudes about brand name versus generic preparation.^14,15

Physicians’ knowledge of drug costs Studies conducted in the 1970s and each decade thereafter have shown that physicians have a poor knowledge of drug costs.^15-23 In the 1970s, physicians mentioned cost as a reason for choosing a drug less than 6% of the time. Many said they did not even consider cost when prescribing.²⁴ Further research suggested that physicians were unaware of the financial impact of the care they provided, leading to the realization that physicians need education about drug costs.^24,25 Unfortunately, later studies indicated that physicians in family medicine,^15,19 internal medicine,¹⁵ pediatrics,²⁶ neurology,²⁷ and geriatrics¹³ continued to have poor knowledge of medication costs.²¹

PAs’ knowledge of drug costs Parallel research regarding PAs’ knowledge of drug costs or their attitudes about prescribing drugs is limited. A 1984 study assessed PA prescribing behavior and attitudes without assessing drug cost knowledge.²⁸ PAs have prescriptive authority in 48 states,²⁹ and in 2004 alone, they prescribed 250 million medications.³⁰ Since PAs work in more than 90% of the specialties that treat elderly patients, it is important that their knowledge of drug costs also be examined.³¹

The purpose of the current study was to assess PA attitudes regarding prescribing prescription medications and their knowledge of drug costs. Goals were to answer the following questions: (1) What knowledge do PAs have regarding actual drug costs? (2) Do PAs actively try to keep drug costs down for their patients? (3) What are the attitudes of PAs regarding prescribing drugs? (4) Do knowledge and prescriptive attitudes of PAs differ by practice specialty? (5) Do knowledge and prescriptive attitudes of PAs differ by practice setting?

Methods

Study design This study employed a mail survey based on one that assessed physicians’ prescribing attitudes and knowledge of prescription medication costs.²¹ The survey was modified for PAs for the purposes of this study. There were six questions on demographics, followed by eight on prescribing patterns and resources. The final section of the survey instrument was designed to measure PA knowledge of the relative costs of 30 different drugs for a 1-month supply. Medications used for this part of the survey instrument were taken from a report by the Families USA group in 2003.¹

The survey instrument was pretested on six PA faculty from Western Michigan University (WMU) as well as on six committee members from the physician assistant clinical knowledge rating and assessment tool (PACKRAT) test item writers group from the Association of Physician Assistant Programs (now Physician Assistant Education Association). These participants are PA faculty members from various PA programs from across the country.

Subject selection The target population for this study was PAs who reside in the state of Michigan. The author obtained a list of all 1,958 Michigan PAs from the Michigan Department of Consumer and Industry Services. A sample size optimization analysis showed that a survey sample of 323 PAs would sufficiently reflect the target population. Since a realistic response rate for a mail survey is 30% to 60%,32 the survey was sent to 1,079 randomly selected PAs. Hoping to maximize the response rate to more than 30%, the author sent a postcard 3 weeks after the original mailing reminding the selected participants to complete the survey instrument if they had not yet done so, or thanking them for their participation if they had completed and returned the survey instrument.³³

Data analysis Demographic information was collected regarding gender, professional role, practice setting, length of practice, professional degree, and practice specialty. Data from the survey instrument were examined using descriptive statistics utilizing mean and proportions. Inferential statistics explored possible differences in responses among the different variables of medical specialty and practice setting. The drug cost knowledge portion of the survey instrument was scored by calculating the number of correct responses from the number of those attempted. This method took into consideration that not all specialties utilize all of the drug preparations that were listed on the survey instrument. All statistical analysis was performed utilizing the Statistical Package for the Social Sciences (SPSS).

Results

Of the 1,079 survey instruments sent out, 295 were returned for a response rate of 27.3%. Of those returned, 7 respondents no longer practiced as PAs and 57 filled out the survey instrument incorrectly. Since this study focused on PAs who treat Medicare recipients, 8 participants who were employed within pediatrics and 9 employed in occupational medicine settings were excluded. Hence, a total of 214 survey instruments (72.5% of those returned) were suitable for data analysis (see Table 1).

Data were then subdivided into two categories: 1) survey instruments where respondents indicated that drug cost was considered when making a prescription decision (n = 182); and 2) survey instruments where respondents indicated that drug cost was not considered when making a prescription decision (n = 32). Among participants in the latter group, 47% were in a surgery subspecialty, and 50% were employed within the inpatient setting. These participants were told to stop the survey since they did not consider drug costs, and they were not included in further analyses.

Knowledge of drug costs Overall, 40% of those who returned acceptable surveys correctly identified the actual cost range of a 1-month supply of the drugs listed on the survey instrument. PAs practicing in medical specialties and surgery comprised 33% to 40%, while all other PA specialties comprised more than 40% (see Figure 1).

Trying to keep drug costs down PAs were asked whether they actively try to keep drug costs down. Most respondents (88%) indicated that they ask about their patient’s ability to pay for medications before choosing a drug. Whether respondents were concerned about the cost of medications differed, depending on the type of insurance held by the patient. If the patient’s insurance was Medicaid, 71% indicated concern; for Medicare, 89%; for self-pay, 96%; and for HMO, 60% (see Figure 2). These responses suggest that PAs do, indeed, make a conscious effort to keep costs down.

Attitudes about prescribing drugs Most respondents (73%) indicated that the affordability of a given drug affects their prescribing decisions more than the efficacy of the chosen drug (see Figure 3). Most of the respondents (86%) stated that the patient’s type of prescription drug insurance influenced their prescriptive choices. The responses clearly indicate that PAs are concerned about making prescribing decisions based upon the patient’s ability to pay and that the patient’s insurance does influence their prescriptive choice. Fewer than half of the respondents (47%) expressed a tendency to prescribe generic drugs more than brands.

Differences by practice specialty A series of one-way way analysis of variances (ANOVAs) was used to determine whether there were significant differences by practice specialty in survey question responses. There was such a difference in whether respondents asked patients about their ability to pay for the medications before making prescription decisions (F = 4.914, df = 6, 175; P = .000). Post hoc analysis revealed that the significant difference was between the general internal medicine and surgery subspecialty groups (Tukey HSD, P = .006).

There was a significant difference by practice specialty regarding whether prescribing decisions are based on the patient’s ability to afford the drug rather than on its efficacy (F = 2.616, df = 6, 175; P = .019). Post hoc analysis demonstrated that the significant difference was between the surgery subspecialty and general family practice (P = .011), internal medicine subspecialty (P = .040), and other (P = .024) specialty groups. This suggests that PAs employed in surgical subspecialties are not as concerned about drug costs.

There was also a significant difference by practice specialty regarding whether the patient’s type of prescription drug insurance influenced prescription choices (F = 2.749, df = 6, 175; P = .014). Post hoc analysis demonstrated that the difference was between the general family practice and surgery subspecialty groups (P = .031). PAs employed in family practice consider their patients’ insurance when prescribing medications.

Differences by practice setting A series of independent t-tests determined if responses differed by practice setting (inpatient versus outpatient). There was a significant difference by practice setting in responses to the question regarding whether the patient’s ability to pay for the medications was considered before a drug was chosen (t = 2.515, df = 171, P = .013). This suggests that PAs who are employed in inpatient settings are less likely to consider their patients’ ability to pay for the medications.

There was a significant difference by practice setting concerning whether the prescription drug insurance of the patient was considered when choosing a drug (t = –2.947, df = 171, P = .004). This suggests that PAs who work in the inpatient setting are not as concerned about insurance coverage.

There was also a significant difference by practice setting regarding whether brand name drugs were prescribed more often than generic drugs (t = 2.406, df = 71, P = .017). This suggests that PAs working within the inpatient settings prescribe more brand name drugs than do PAs who work in the outpatient settings.

Discussion and conclusion

The findings of this study are similar to those of studies done on physicians during the past 30 years.^15-23 While both physicians and PAs consider drug costs to be an important consideration, knowledge of those costs is lacking. Findings from this study are similar to those of physician studies regarding overestimation and underestimation of drug costs.^16,19 The results of this study indicate that 60% of the time, surveyed PAs do not know the actual cost of their patients’ drugs, but results vary according to medical specialty and practice setting. PAs practicing in surgery subspecialties who responded to this survey were less likely to consider a patient’s ability to pay for medications and less concerned about drug costs. By comparison, PAs practicing in general internal medicine were more likely to ask about a patient’s ability to pay for medication and more likely to consider a patient’s insurance when making prescriptive decisions. The differences may result from the particular therapeutics used in surgical practices, which may limit drug selection and availability. This may lead PAs to select drugs that most often lack competition and therefore tend to be more expensive (ie, brand name instead of generic drugs).

Role of practice setting It was also noteworthy that practice setting played a significant role. Respondents who worked in inpatient settings were less likely to consider their patients’ ability to pay for the medications, less concerned about insurance coverage, and more likely to prescribe more brand name drugs than were PAs not working in an inpatient setting. PAs in inpatient settings may feel less restricted when ordering medications for their patients, whereas those in outpatient settings can be constrained by what their patients can afford.

More education needed Findings from previous physician studies have indicated the need for better education regarding drug costs as well as access to information about drug costs.^21,22,24,34 Studies have shown that an educational program on drug therapeutics and costs increases physician knowledge and decreases patients’ expenses and that the number of educational sessions increases the amount of knowledge.^26,35,36

The results of the present study are similar to the findings of research on physicians and suggest that PAs would benefit from more education about drug costs both while they are in PA school and later on through continuing education. PA programs should continue to emphasize the importance of drug costs and the impact that these particular expenses have on all patient populations, especially the Medicare population. Medicare Part D may provide some relief to older patients, but PAs will still have to be educated about drug costs and make a conscious effort to keep medical costs down.

Limitations and implications for future research The current study was subject to all of the limitations that apply to mail surveys, such as low response rate, limited depth of information, and no way to explain instructions. Although the survey did not achieve the desired response rate of 30%, the data are still meaningful and can serve as the basis for future studies.

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