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Editor—At the risk of annoying my Canadian friends who reported the influence of direct to consumer pharmaceutical advertising and patients' requests on prescribing,1 I would point out two studies published in JAMA.
Firstly, Allison et al found that doctors at major teaching hospitals properly prescribed β blockers (and other drugs) more frequently than did doctors at minor teaching hospitals and non-teaching hospitals.2 For β blockers, for example, major teaching hospitals prescribed them 48.8% of the time, minor teaching hospitals 40.3% of the time, and non-teaching hospitals 30.4% of the time.
Secondly, Jencks et al similarly found that, overall, doctors in the United States prescribed β blockers 24 hours after the myocardial infarction slightly more than 50% of the time.3
Earlier, the private insurer United Health Care had found that doctors under contract with it prescribed β blockers only about half the time that they ought to have done. According to the literature, there seems to be a consensus that β blockers in such cases should be given to all such patients. Finally, in a recent study in Germany it was found that, under the disease management that that country now tries to adopt, the use of prescription drugs might well increase.
Would it be harmful if Americans were told on television and in the print media that patients should receive β blockers after a myocardial infarction? Can we be sure that the prescription rate in the absence of television advertising is the proper benchmark? We need to go a step further and determine the proper benchmark for the use of prescription drugs. The issue here, as elsewhere in health care, is not how much is spent under differing arrangements but what difference different levels of health spending make to quality of life.
What is needed, ultimately, is a series of well endowed pharmacoeconomic research institutes that are, by virtue of their endowments, completely independent of funding by government, the insurance industry, and the pharmaceutical industry. Such institutes could undertake objective benefit:cost analyses of different pharmaceutical products and also determine the proper benchmarks for drug use.