Football pictureConversation at a football game

Me: Remember when you used to get to go to football games and watch football. Now every game is televised and there are commercials playing for the folks watching on TV. Meanwhile, IT IS COLD

My (somewhat older) friend: Yeah, but the commercials are likely for some drug or another. That seems to be all they advertise. People sitting around in bath tubs,

My friend’s wife: But then you hear the side effects “you might die slowly, you might die quickly, you might die without major organs, you might have an erection lasting 4 hours then die.” Do people actually ask you for those drugs?

Me: I’m sure the drug companies know exactly how much they make off the ads. Big Pharma knows everything about my prescribing habits. The NSA got nothing on them. Oh, look, the media guy is winding his arm. Maybe we’ll get to watch some football. BRRRRR!

I am the wrong person to ask about drug advertising. We have patients who are on public assistance so by necessity I pay a lot of attention to the cost to the patient and to the state of Alabama. We have pharmacists working for us to make sure that we chose medication based on evidence and best practices. When ProPublica did an expose on doctor’s prescribing habits (found here), I prescribed (including residents prescribing in my name) 85% generic drugs which though not the lowest was very, very low.

It did bring to mind another conversation I had this past week, though, with one of my residents about working in an “urgent care” setting. He has decided that this is the clinical life for him once he graduates. He finds solace in the fact that in doing this job  he will be keeping people out of the emergency room. The faculty in the room tried to convince him that such a practice would not be for him. As a part of our efforts I found a listing of the common complaints, diagnoses, and prescribing patterns for urgent care encounters from 2008 (found here). About 40% of the visits were for colds, earaches, and whatnot and about 50% of all the prescriptions were for antibiotics. Urgent care docs, by their estimation, wrote 6.5 million Z-pack prescriptions. That is a lot of medication for what I presume is an illness that’ll likely go away on its own (the old doctor’s adage is that a cold will last for 10 days without antibiotics and a week and a half with antibiotics).

Since the game was 30-0, that got me to thinking about direct to consumer (DTC) advertising. One of the things DTC advertising does, and a reason physicians tolerate it, is that advertising increases demand for services. Want a blue pill for your bathtub friend? Gotta go to the doctor. What was once heartburn is now Gastroesophageal Reflux Disease and demands treatment with the purple pill. Has there been DTC advertising for antibiotics? Could this be part of the reason for the Immediate Care proliferation?

Turns out the answer to my first question was yes. Zithromax, the number one prescribed urgent care pill, is the subject of a $6,000,000 settlement for false claims made in DTC advertising. Part of the settlement is a requirement to pay for this advertising verbiage:

Remember that antibiotics do not work for viral infections, such as cold or flu, so do not insist on a prescription for an antibiotic. Only your doctor can decide what type of infection your child has and the best way to treat it.

It has been estimated that as many as 50% of antibiotic prescriptions are unnecessary. Here in the deep south, we get over 1 prescription per person per year for antibiotics, and many of those are for azythromycin (brand name Zithromax). This is twice as many antibiotic prescriptions as in other regions of the country, and yet folks are not dying of infections in larger numbers in those areas. Go figure.

Where I left my resident (and my cold football friends) is that under the Affordable Care Act this will likely change. In part I suspect that the high deductible  will lead people to investigate alternatives to antibiotics for non-infectious illness. The antibiotic is less expensive than the office visit leading to the antibiotic and many are going to, I anticipate, forego the “Immediate care.” Additionally, I anticipate there will be alternatives to fee-for-service models of care for upper respiratory type symptoms. Many people come to the office and get an antibiotic in part to obtain a work excuse. Maybe, if the physicians gets paid differently, he or she will give the excuse without the fiction that the patient needs a Z-pack.