This analysis of geographic variation in the rates of prescription of high-risk drugs for use by elderly populations provides disheartening evidence that our healthcare quality is flawed. I was particularly interested in the fact that areas with high rates of prescribing in general were not found to be associated high rates of prescribing these high-risk drugs. This finding and the wide range of rates in different regions both suggest that causality of this worrisome phenomenon may be rather complex. I also found it intriguing that the region with the lowest rate of elderly individuals on high-risk drugs was the Bronx (with a rate of 11 percent). One might expect that an urban area might have a greater proportion of elderly individuals on such drugs due to the lifestyle and environmental conditions which are inherent to city living. This study certainly implies the need for further research in this area. We can see that drastic variation in the quality of prescribing is evident across geographic regions, but the article does not suggest why this might be the case. Possibilities might include medical training variation or even the influence of drug companies in particular regions. More research is called for.
I concord with Nik's view on this interesting article on high-risk drug prescription in older population across country. Looking into the quality of prescription is very innovative approach to address and improve the overall quality of health care. In addition to Nik's point of lack of association between overall high rates of prescribing and high-risk drugs, it is noteworthy that areas with such low quality prescriptions are associated with increased medical cost (excluding drugs). Also the HEDIS quality measures for high-risk medication and disease-drug interaction are similar. This could be attributed to the overlap of drugs in both the categories. It would be interesting to see such quality prescription in some of the prevalent chronic conditions like hypertension, diabetes and arthritis. It will be a complete new task now to look into the determinants of quality prescription and calls for more standardized drug prescription protocols and continual physician education on high-risk drugs prescription in elderly. It would also be interesting to look into the role of providers involved in quality drug prescription to elderly i.e. Internist, FPs, Geriatricians, Hospitalists and compare the outcomes.
This article rigorously examined the relationship between expenditure and quality. It implicated that more health expenditure would not necessarily lead to higher-quality health care. The methodologies employed in this research assured its validity. But I will prefer to interpret the results in another way.
Let’s first briefly describe the study. Evidence has shown that quantity of the prescription consumption varies significantly across hospital-referral regions (HRR). Studies also focus on the association of quantity of prescription consumption and the overall medical spending. But little research addresses the correlation between the quality of prescription and the health expenditure including spending on drug and the overall medical performance, which is definitely important and deserve more thorough discussion. Therefore this study investigated the variation of the quality of prescription across HRR , followed by the comparison to the variation of medical spending that is already known. Relationship between the intense of low-quality prescription performance and health expenditure was also examined. Three main results were presented: first, variations of performance of low-quality prescription were confirmed, which was proved to be even higher than that of the medical spending. Second, the low-quality prescription performance was found to be weakly positively correlated to the overall drug spending but remarkably correlated with the overall medical spending, which include all the medical expenditure not just on drugs.
Both the first two result indicated that relationship between poor quality prescription performance and spending. The second result implied the underlying information that the poor quality prescription may account relatively a small part for the total consumption on drugs. The third result indicated that low-quality prescription would contribute to more health expenditure in total. Combining these three results, we might infer that low-quality prescription performance will not necessary lead to more consumption on other drugs that might be used to offset or treat the corresponding adverse effects, but call for more consumption on health resources other than drugs, such as the employment of medical device or lengthening of hospitalization. More research will be absolutely needed to explore the reasons for the relationship. Besides, another two explanations may also be inferred from these two results. For one aspect, It will be possible that regions with higher low quality prescription practices might also experizlence lower appropriate prescription practices, which could offset the impact of inappropriate prescription practice on the overall drug utilization. This, in hence, draw to the inference that the situation in these regions may be worse. For another, it will be also possible that the proportion of low-quality prescription practice was so small that any significant variations in it could not elicit significant change on the overall cost drug in that region. Well, from this aspect, should we also feel not that depressed about the results? I believe the data employed in this research did have the power to give us more information in details, which may lead to different policy implications eventually.
The author concluded on that higher spending would not necessarily result in better health care. However, I might have to doubt the efficacy to draw this conclusion from this article. This article successfully and convincingly presented the variations of the quality of prescription across regions. It even has desirably and reasonably proposed that low-quality prescription performance might have driven the cost through some way other than the utilization of more drugs for the treatment of adverse events. But it did not provide evidence that higher cost would lead to the prescription performance of similar or even worse quality. Therefore, though much evidence has indicated the weak efficacy of increasing medical cost on improving quality of care, this research could not support that debate. More information will be needed in the future to draw that conclusion.
In a word, this article clearly proposed a new perspective in investigating the relationship between cost and quality, the immortal theme on the journey of health reform. But more information could have been provided from the data, and more attention should have been paid to draw parts of conclusions.
This indeed is an innovative method for health services research. I am not expert on how to define high-risk drugs. There is a possibility that the elderly patients living in the high-risk areas are just sicker and have indicators for harmful drugs (because the low-risk drugs don't have therapeutic effects). Hence, I think the second map about the potentially harmful drug-disease interactions provide more useful information because the interaction is an more accurate indicator for quality of prescribing. It appears that quality of prescribing has nothing to do with income status. For example, Virginia is one of the richest region in the states. However, it was not performing well in the prescribing quality category based on this map. However, Michigan, which was hit hard by economic downturn, had lower risk than most states. It will be interesting to do an analysis on a state with both high-risk and low-risk areas in order to determine the risk factors for harmful drug prescription. Some states for selection include California, Florida, and Michigan.
I agree with the point that this research clearly has proposed a new field of study in the quality of care. As Chintan said, quality of prescription may be a good indicator on quality of health and deserves more research. It did present some important and very interesting results. But as pointed out by Nik, the underlying reason for the geographic variation of prescription is still unknown. Though this research implied certain association between the variation and the spending on drugs as well as overall medical services, it did not present evidence that whether such variation can be explained by the difference in spending. I agree with Nik that it might be very interesting to investigate further why places with higher drugs spending do not necessarily witness higher rate of low quality prescription. Besides, as what Yanen mentioned, it is still not clear about why physicians in richer states will not necessarily perform better prescription.
All this comments strengthened my inference that it might be a little early to conclude the relationship between spending and quality of care. Quality of care might have been attributed less to the influence of health expenditure than people think before. Health expenditure may affect quality of care through the allocative efficiency in terms of availability and accessibility of the health services. It may also influence the productive efficiency by mediating physicians and patients’ behaviors, which may be attributed to many factors except for economic incentives, such as education background, guideline recommendations, individual preferences, community culture, etc. However, when resources are available, how to use those resources to serve the best might be less to do with expenditure. How is the physician educated in prescription? What’s his experience on the similar situations? Is he an adventurer who will vote for the risky drugs for the sake of even tiny chance of success? Does the patient play an important role in determining the treatment plans he will receive? What does the guideline recommend? All of these could be hardly merely explained by financial effects, albeit reimbursement for the physicians and economic status of the patients should be taken into account.
From this point of view, it might be reasonable to expect better quality of care even when expenditure is controlled. Rather than direct financial investment, efforts on reducing wastes, improvement on continuous education and research on clinical protocol may be more cost effective.
This analysis of geographic variation in the rates of prescription of high-risk drugs for use by elderly populations provides disheartening evidence that our healthcare quality is flawed. I was particularly interested in the fact that areas with high rates of prescribing in general were not found to be associated high rates of prescribing these high-risk drugs. This finding and the wide range of rates in different regions both suggest that causality of this worrisome phenomenon may be rather complex. I also found it intriguing that the region with the lowest rate of elderly individuals on high-risk drugs was the Bronx (with a rate of 11 percent). One might expect that an urban area might have a greater proportion of elderly individuals on such drugs due to the lifestyle and environmental conditions which are inherent to city living. This study certainly implies the need for further research in this area. We can see that drastic variation in the quality of prescribing is evident across geographic regions, but the article does not suggest why this might be the case. Possibilities might include medical training variation or even the influence of drug companies in particular regions. More research is called for.
ReplyDeleteI concord with Nik's view on this interesting article on high-risk drug prescription in older population across country. Looking into the quality of prescription is very innovative approach to address and improve the overall quality of health care. In addition to Nik's point of lack of association between overall high rates of prescribing and high-risk drugs, it is noteworthy that areas with such low quality prescriptions are associated with increased medical cost (excluding drugs). Also the HEDIS quality measures for high-risk medication and disease-drug interaction are similar. This could be attributed to the overlap of drugs in both the categories. It would be interesting to see such quality prescription in some of the prevalent chronic conditions like hypertension, diabetes and arthritis. It will be a complete new task now to look into the determinants of quality prescription and calls for more standardized drug prescription protocols and continual physician education on high-risk drugs prescription in elderly. It would also be interesting to look into the role of providers involved in quality drug prescription to elderly i.e. Internist, FPs, Geriatricians, Hospitalists and compare the outcomes.
ReplyDeleteThis article rigorously examined the relationship between expenditure and quality. It implicated that more health expenditure would not necessarily lead to higher-quality health care. The methodologies employed in this research assured its validity. But I will prefer to interpret the results in another way.
ReplyDeleteLet’s first briefly describe the study. Evidence has shown that quantity of the prescription consumption varies significantly across hospital-referral regions (HRR). Studies also focus on the association of quantity of prescription consumption and the overall medical spending. But little research addresses the correlation between the quality of prescription and the health expenditure including spending on drug and the overall medical performance, which is definitely important and deserve more thorough discussion. Therefore this study investigated the variation of the quality of prescription across HRR , followed by the comparison to the variation of medical spending that is already known. Relationship between the intense of low-quality prescription performance and health expenditure was also examined. Three main results were presented: first, variations of performance of low-quality prescription were confirmed, which was proved to be even higher than that of the medical spending. Second, the low-quality prescription performance was found to be weakly positively correlated to the overall drug spending but remarkably correlated with the overall medical spending, which include all the medical expenditure not just on drugs.
Both the first two result indicated that relationship between poor quality prescription performance and spending. The second result implied the underlying information that the poor quality prescription may account relatively a small part for the total consumption on drugs. The third result indicated that low-quality prescription would contribute to more health expenditure in total. Combining these three results, we might infer that low-quality prescription performance will not necessary lead to more consumption on other drugs that might be used to offset or treat the corresponding adverse effects, but call for more consumption on health resources other than drugs, such as the employment of medical device or lengthening of hospitalization. More research will be absolutely needed to explore the reasons for the relationship. Besides, another two explanations may also be inferred from these two results. For one aspect, It will be possible that regions with higher low quality prescription practices might also experizlence lower appropriate prescription practices, which could offset the impact of inappropriate prescription practice on the overall drug utilization. This, in hence, draw to the inference that the situation in these regions may be worse. For another, it will be also possible that the proportion of low-quality prescription practice was so small that any significant variations in it could not elicit significant change on the overall cost drug in that region. Well, from this aspect, should we also feel not that depressed about the results? I believe the data employed in this research did have the power to give us more information in details, which may lead to different policy implications eventually.
Continued....
ReplyDeleteThe author concluded on that higher spending would not necessarily result in better health care. However, I might have to doubt the efficacy to draw this conclusion from this article. This article successfully and convincingly presented the variations of the quality of prescription across regions. It even has desirably and reasonably proposed that low-quality prescription performance might have driven the cost through some way other than the utilization of more drugs for the treatment of adverse events. But it did not provide evidence that higher cost would lead to the prescription performance of similar or even worse quality. Therefore, though much evidence has indicated the weak efficacy of increasing medical cost on improving quality of care, this research could not support that debate. More information will be needed in the future to draw that conclusion.
In a word, this article clearly proposed a new perspective in investigating the relationship between cost and quality, the immortal theme on the journey of health reform. But more information could have been provided from the data, and more attention should have been paid to draw parts of conclusions.
This indeed is an innovative method for health services research. I am not expert on how to define high-risk drugs. There is a possibility that the elderly patients living in the high-risk areas are just sicker and have indicators for harmful drugs (because the low-risk drugs don't have therapeutic effects). Hence, I think the second map about the potentially harmful drug-disease interactions provide more useful information because the interaction is an more accurate indicator for quality of prescribing.
ReplyDeleteIt appears that quality of prescribing has nothing to do with income status. For example, Virginia is one of the richest region in the states. However, it was not performing well in the prescribing quality category based on this map. However, Michigan, which was hit hard by economic downturn, had lower risk than most states. It will be interesting to do an analysis on a state with both high-risk and low-risk areas in order to determine the risk factors for harmful drug prescription. Some states for selection include California, Florida, and Michigan.
I agree with the point that this research clearly has proposed a new field of study in the quality of care. As Chintan said, quality of prescription may be a good indicator on quality of health and deserves more research. It did present some important and very interesting results. But as pointed out by Nik, the underlying reason for the geographic variation of prescription is still unknown. Though this research implied certain association between the variation and the spending on drugs as well as overall medical services, it did not present evidence that whether such variation can be explained by the difference in spending. I agree with Nik that it might be very interesting to investigate further why places with higher drugs spending do not necessarily witness higher rate of low quality prescription. Besides, as what Yanen mentioned, it is still not clear about why physicians in richer states will not necessarily perform better prescription.
ReplyDeleteAll this comments strengthened my inference that it might be a little early to conclude the relationship between spending and quality of care. Quality of care might have been attributed less to the influence of health expenditure than people think before. Health expenditure may affect quality of care through the allocative efficiency in terms of availability and accessibility of the health services. It may also influence the productive efficiency by mediating physicians and patients’ behaviors, which may be attributed to many factors except for economic incentives, such as education background, guideline recommendations, individual preferences, community culture, etc. However, when resources are available, how to use those resources to serve the best might be less to do with expenditure. How is the physician educated in prescription? What’s his experience on the similar situations? Is he an adventurer who will vote for the risky drugs for the sake of even tiny chance of success? Does the patient play an important role in determining the treatment plans he will receive? What does the guideline recommend? All of these could be hardly merely explained by financial effects, albeit reimbursement for the physicians and economic status of the patients should be taken into account.
From this point of view, it might be reasonable to expect better quality of care even when expenditure is controlled. Rather than direct financial investment, efforts on reducing wastes, improvement on continuous education and research on clinical protocol may be more cost effective.