Journal of General Internal Medicine

, Volume 21, Issue 7, pp 694–697

Over and under-utilization of cyclooxygenase-2 selective inhibitors by primary care physicians and specialists

The tortoise and the hare revisited
  • Brian D. De Smet
  • A. Mark Fendrick
  • James G. Stevenson
  • Steven J. Bernstein
Original Articles

Abstract

OBJECTIVES: To compare prescribing trends and appropriateness of use of traditional and cyclooxygenase-2 selective (COX-2) nonsteroidal anti-inflammatory drugs (NSAIDs) by primary care physicians (PCPs) and specialists.

DESIGN: Retrospective cohort study.

PATIENTS: One thousand five hundred and seventy-six adult patients continuously enrolled for at least 1 year with an independent practice association of a University-associated managed care plan who were started on a traditional NSAID or a COX-2 inhibitor from 1999 to 2002 and received at least 3 separate medication fills.

MEASUREMENTS: Physician specialty was identified from office visits. Appropriateness of utilization was based on gastrointestinal risk characteristics.

RESULTS: Primary care patients were younger and less likely to have comorbid conditions. Despite similar GI risk, COX-2 use among patients seen by PCPs was half that of patients seen by specialists (21% vs 44%, P<.001). While PCPs overused cyclooxygenase-2-specific inhibitors (COX-2s) less often than specialists (19% vs 41%, P<.001), they also tended to underuse COX-2s in patients who were at increased GI risk (46% vs 32%, P=.063). This represents a 3-fold and 8-fold difference in overuse versus underuse for PCPs and specialists, respectively.

CONCLUSIONS: Using COX-2s as a model for physician adoption of new therapeutic agents, specialists were more likely to use these new medications for patients likely to benefit but were also significantly more likely to use them for patients without a clear indication. This study demonstrates the tension between appropriate adoption of innovative therapies for those individuals who would benefit from their use and those individuals who would receive no added clinical benefit but would incur added cost and be placed at increased risk.

Key words

primary care appropriateness COX-2 practice patterns specialist 

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References

  1. 1.
    Center for American Progress. No Relief for Rising Drug Costs. Available at: http://www.americanprogress.org/site/pp.asp?c=biJRJ8OVF&b=83161. Accessed January 31, 2005.Google Scholar
  2. 2.
    Ayanian JZ, Guadagnoli E, McNeil BJ, Cleary PD. Treatment and outcomes of acute myocardial infarction among patients of cardiologists and generalist physicians. Arch Intern Med. 1997;157:2570–6.PubMedCrossRefGoogle Scholar
  3. 3.
    Chin MH, Zhang JX, Merrell K. Specialty differences in the care of older patients with diabetes. Med Care. 2000;38:131–40.PubMedCrossRefGoogle Scholar
  4. 4.
    Chin MH, Friedmann PD, Cassel CK, Lang RM. Difference in generalist and specialist physicians’ knowledge and use of angiotensin-converting enzyme inhibitors for congestive heart failure. J Gen Intern Med. 1997;12:523–30.PubMedCrossRefGoogle Scholar
  5. 5.
    Donohoe MT. Comparing generalist and specialty care. Arch Intern Med. 1998;158:1596–608.PubMedCrossRefGoogle Scholar
  6. 6.
    Fendrick AM, Garabedian-Ruffalo SM. A clinician’s guide to the selection of NSAID therapy. Pharm Ther. 2002;27:579–82.Google Scholar
  7. 7.
    Peura DA. Gastrointestinal safety and tolerability of nonselective nonsteroidal anti-inflammatory agents and cyclooxygenase-2-selective inhibitors. Cleveland Clin J Med. 2002;69(Suppl. 1):31-SI39.Google Scholar
  8. 8.
    National Institute for Clinical Excellence. Technology Appraisal No. 27. Guidance on the Use of Cyclo-oxygenase (COX) II Selective Inhibitors, Celecoxib, Rofecoxib, Meloxicam and Etodolac for Osteoarthritis and Rheumatoid Arthritis. Available at: http://www.nice.org.uk/pdf/coxiifullguidance.pdf. Accessed January 31, 2005.Google Scholar
  9. 9.
    Fendrick AM, Schwartz JS. Physicians’ decisions regarding the acquisition of technology. In: Gelijns AC, Dawkins HV, eds. Medical Innovations at the Crossroads. Vol. 4, Adopting New Medical Technology. Washington, DC: National Academy Press; 1994:71–84.Google Scholar
  10. 10.
    Hirth RA, Fendrick AM, Chernew ME. Specialist and generalist physicians’ adoption of antibiotic therapy to eradicate helicobacter pylori infection. Med Care. 1996;34:204.CrossRefGoogle Scholar
  11. 11.
    Sebaldt RJ, Petrie A, Goldsmith CH, Marentette MA. Appropriateness of NSAID and Coxib prescribing for patients with osteoarthritis by primary care physicians in ontario: results from the CANOAR study. Am J Manage Care. 2004;10:742–50.Google Scholar
  12. 12.
    Tannenbaum H, Peloso PMJ, Russel AS, Marlow B. An evidence-based approach to prescribing NSAIDs in the treatment of osteoarthritis and rheumatoid arthritis: the second canadian consensus conference. Can J Clin Pharmacol. 2000;7(Suppl A):4A-16A.PubMedGoogle Scholar
  13. 13.
    Mamdani M, Juurlink DN, Kopp A, Naglie G, Austin PC, Laupacis A. Gastrointestinal bleeding after the introduction of COX 2 inhibitors: ecological study. BMJ. 2004;328:1415–6.PubMedCrossRefGoogle Scholar
  14. 14.
    Silverstein FE, Faich G, Goldstein JL, et al. Gastrointestinal toxicity with celecoxib vs nonsteroidal anti-inflammatory drugs for osteoarthritis and rheumatoid arthritis. The CLASS study: a randomized controlled trial. JAMA. 2000;284:1247–55.PubMedCrossRefGoogle Scholar
  15. 15.
    Bombardier C, Laine L, Reicin A, et al. Comparison of upper GI toxicity of rofecoxib and naproxen in patients with rheumatoid arthritis. N Engl J Med. 2000;343:1520–8.PubMedCrossRefGoogle Scholar

Copyright information

© Society of General Internal Medicine 2006

Authors and Affiliations

  • Brian D. De Smet
    • 1
    • 2
  • A. Mark Fendrick
    • 3
    • 4
  • James G. Stevenson
    • 1
    • 2
  • Steven J. Bernstein
    • 3
    • 4
    • 5
  1. 1.Department of Pharmacy ServicesUniversity of Michigan Hospitals and Health CentersAnn ArborUSA
  2. 2.Department of Clinical Sciences, College of PharmacyUniversity of MichiganAnn ArborUSA
  3. 3.Department of Internal Medicine, School of MedicineUniversity of MichiganAnn ArborUSA
  4. 4.Department of Health Management & Policy, School of Public HealthUniversity of MichiganAnn ArborUSA
  5. 5.Center for Practice Management and Outcomes ResearchVA Ann Arbor Healthcare SystemAnn ArborUSA

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