Skip to main content

Main menu

  • HOME
  • ARTICLES
    • Current Issue
    • Ahead of Print
    • Archives
    • Abstracts In Press
    • Special Issue Archive
    • Subject Collections
  • INFO FOR
    • Authors
    • Reviewers
    • Call For Papers
    • Subscribers
    • Advertisers
  • SUBMIT
    • Manuscript
    • Peer Review
  • ABOUT
    • The JABFM
    • The Editing Fellowship
    • Editorial Board
    • Indexing
    • Editors' Blog
  • CLASSIFIEDS
  • Other Publications
    • abfm

User menu

Search

  • Advanced search
American Board of Family Medicine
  • Other Publications
    • abfm
American Board of Family Medicine

American Board of Family Medicine

Advanced Search

  • HOME
  • ARTICLES
    • Current Issue
    • Ahead of Print
    • Archives
    • Abstracts In Press
    • Special Issue Archive
    • Subject Collections
  • INFO FOR
    • Authors
    • Reviewers
    • Call For Papers
    • Subscribers
    • Advertisers
  • SUBMIT
    • Manuscript
    • Peer Review
  • ABOUT
    • The JABFM
    • The Editing Fellowship
    • Editorial Board
    • Indexing
    • Editors' Blog
  • CLASSIFIEDS
  • JABFM on Bluesky
  • JABFM On Facebook
  • JABFM On Twitter
  • JABFM On YouTube
Brief ReportBrief Report

Using Drug Prescribing Patterns to Identify Stewards of Cost-Conscious Care

Nicole Michele Gastala, Peter Wingrove, Winston Liaw, Stephen Petterson and Andrew Bazemore
The Journal of the American Board of Family Medicine November 2017, 30 (6) 824-827; DOI: https://doi.org/10.3122/jabfm.2017.06.170019
Nicole Michele Gastala
From Primary Health Care, Inc., Marshalltown, IA (NMG); Robert Graham Center for Policy Studies, Washington, DC (PW, WL, SP, AB).
MD
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Peter Wingrove
From Primary Health Care, Inc., Marshalltown, IA (NMG); Robert Graham Center for Policy Studies, Washington, DC (PW, WL, SP, AB).
BS
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Winston Liaw
From Primary Health Care, Inc., Marshalltown, IA (NMG); Robert Graham Center for Policy Studies, Washington, DC (PW, WL, SP, AB).
MD, MPH
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Stephen Petterson
From Primary Health Care, Inc., Marshalltown, IA (NMG); Robert Graham Center for Policy Studies, Washington, DC (PW, WL, SP, AB).
PhD
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Andrew Bazemore
From Primary Health Care, Inc., Marshalltown, IA (NMG); Robert Graham Center for Policy Studies, Washington, DC (PW, WL, SP, AB).
MD, MPH
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
  • Article
  • Figures & Data
  • References
  • Info & Metrics
  • PDF
Loading

Abstract

Purpose: To characterize family physicians (FPs) who are stewards of care by consistently prescribing omeprazole over esomeprazole.

Methods: Cross-sectional analysis of physicians prescribing omeprazole or esomeprazole under Medicare Part D in 2014.

Results: There was a regional trend with 49% of Western FPs but only 6% of Southern FPs rarely prescribing esomeprazole. Physicians had increased odds of being a steward if they worked with a care coordinator (P < .001), at a patient-centered medical home (P < .001), or in a large practice (P < .001).

Conclusions: If these findings are replicated across multiple drugs, future outreach could be conducted based on provider prescribing patterns.

  • Medicare
  • Prescription Drugs
  • Stewards

Responsible stewardship of health care expenditure is an important movement in an era of increasing costs. The Centers for Medicare and Medicaid Services publicly released comprehensive cost data for all medications in 2013 and 2014 under Medicare Part D.1,2 Brand-only esomeprazole was listed in the top 10 by cost despite the availability of generic therapeutic equivalent omeprazole that is well supported by medical literature.1⇓⇓⇓–5 Although esomeprazole contains only the active S-enantiomer whereas omeprazole contains an equal mix of the S-Enantiomer and R-enantiomer, many studies show no significant difference in efficacy.3⇓–5 Preferred and nonpreferred brand medications carry a higher total cost and copayment cost compared with generic medications under Medicare Part D prescription drug plans.6 Preferential prescribing of esomeprazole over omeprazole can result in a significant financial burden to Medicare Part D patients who paid an average of 10.5 times more for the branded medication.6 This data release presents an opportunity to evaluate prescribing habits of family physicians (FPs) to help target future evidence-based responsible stewardship interventions. The objective of this analysis was to identify and characterize stewards of cost-conscious prescribing.

Methods

We used Medicare Part D data from 2014 to examine prescribing patterns of physicians. This data lists which drugs each physician prescribed, how many days were prescribed, and the cost. We restricted this analysis to prescriptions of esomeprazole (introduced 2001) and generic prescriptions of omeprazole (introduced 1989). We defined stewards as physicians who prescribed esomeprazole less than 2% of the time rather than 0% as this accommodates rare events difficult to control by providers who may in normal circumstances never choose to prescribe esomeprazole. To exclude physicians who did not prescribe either drug frequently, we further restricted the analysis to physicians who prescribed 3650 days or more combined.

We used data from the American Board of Family Medicine to take a closer look at a sample of these physicians, board-certified FPs who recertified in 2014 or 2015. Information on practice size, working at a patient centered medical home (PCMH), and working alongside a care coordinator was self-reported as part of the recertification process. We excluded physicians initially certifying because we lacked data on their practice setting.

We obtained information about each physician’s sex, country of training, year of graduation from medical school, and type of degree obtained from the American Medical Association (AMA) Physician Masterfile. Roughly 94% of the physicians in our sample were successfully matched with AMA records. Each physician’s address was geocoded to determine region of the country and whether they practiced in a nonmetropolitan county as defined by a Rural-Urban Continuum Codes ≥ 4.

We calculated the percent of physicians identified as stewards across a number of physician demographics and practice characteristics. χ2 tests were used to identify statistically significant differences with a threshold of P < .05 used to determine significance. Multivariate logit regression was used to assess the relationship between the likelihood each physician was a steward and our identified physician and practice characteristics.

Results

There were 15,688 FPs who both appeared in Part D Data for 2014 and recertified in 2014 or 2015. There were 8,792 FPs who met our threshold for significant prescribing; this subset accounted for 94.2% of all omeprazole and esomeprazole recorded days supplied in the Part D data.

Overall, 15.0% of the prescriptions were for esomeprazole. The median physician prescribed esomeprazole 13.0% of the time. As defined as prescribing only esomeprazole less than 2% of the time, 2001 (22.8%) physicians met our criterion for being a steward (Figure 1). Approximately 27% of women were stewards, but only 20% of men were. (P < .001).

Figure 1.
  • Download figure
  • Open in new tab
Figure 1.

Distribution of physician prescribing behavior for choosing esomeprazole over omeprazole.

There were significant differences based on practice characteristics. Nearly half of physicians practicing in the West were stewards, but the same was true of only 1 in sixteen physicians from the South. (P < .001) Urban FPs were more likely to not prescribe esomeprazole than their rural counterparts. (P < .001) Physicians who practiced alongside 20 or more providers were 3 times as likely as solo practitioners. (P < .001) Physicians who worked in PCMHs were approximately 50% more likely to be stewards as those who did not (P < .001). The same was true for those working with care coordinators (P < .001).

Multivariate logit regression revealed that many of these differences remain significant when holding other factors constant (Figure 2). Region alone explains much of the variation. Compared with physicians in the Midwest, Southern physicians were one fifth as likely to be stewards (P < .001), and physicians in the Northeast were a little more than half as likely. In contrast, physicians practicing in the West were roughly 2.5 times as likely to be (P < .001). Practice size was also a key determinant. Physicians at medium and large practices were 63% (P < .001) and 145% (P < .001) more likely respectively to be stewards than solo practitioners. Independent of practice size, working with a care coordinator (P < .001) or in a PCMH (P < .001) each increased the likelihood of being a steward by approximately 50%. The effects of demographics were more modest with women being a third more likely than men to be stewards. Physicians who graduated medical school before 1980 were less likely to be stewards than those graduating since 2000.

Figure 2.
  • Download figure
  • Open in new tab
Figure 2.

Practice characteristics and other factors that increase likelihood of being a steward of health care expenditure as defined as prescribing generic omeprazole over esomeprazole (Nexium).

Discussion

In this analysis of Medicare Part D data, we found that 23% of our sample are prescribing stewards. Women, living in the West, and working in large practices that are PCMHs are associated with stewardship. Efforts to help physicians and patients engage in evidence-based conversations aimed at wise management and just distribution of finite resources were created with programs such as the Choosing Wisely campaign by the American Board of Internal Medicine Foundation.7,8 The campaign consists of recommendations based on topics of care but has not targeted specific geographic areas or populations based on physician or practice characteristics related to increased expenditure.

Although more research needs to be conducted, future outreach programs could be directed based on practice or provider specific data to improve prescribing habits. Academic detailing through evidence-based information by specially trained noncommercial outreach educators to physician offices has been shown to be effective in more than 60 randomized controlled trials and could be targeted to specific locations or practice characteristics from future studies such as this.9 Furthermore, with the emergence of health care systems, there are opportunities for information feedback where physicians could be rewarded for prescribing drugs optimally.9

Appendix

View this table:
  • View inline
  • View popup
Appendix:

Demographics and Practice Characteristics

Notes

  • This article was externally peer reviewed.

  • Funding: none.

  • Conflict of interest: none declared.

  • To see this article online, please go to: http://jabfm.org/content/30/6/824.full.

  • Received for publication February 5, 2017.
  • Revision received May 12, 2017.
  • Accepted for publication May 15, 2017.

References

  1. 1.↵
    Centers for Medicare & Medicaid Services (CMS). CMS releases prescriber-level Medicare data for first time. Baltimore, MD, Apr 30, 2015. Available from: https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2015-Fact-sheets-items/2015-04–30.html. Accessed Mar 17, 2016.
  2. 2.↵
    Centers for Medicare & Medicaid Services (CMS). Part D Prescriber Data CY 2014. Baltimore, MD, Aug 18, 2016. Available from: https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/Medicare-Provider-Charge-Data/PartD2014.html. Accessed Oct 17, 2016.
  3. 3.↵
    Congressional Budget Office. Effects of using generic drugs on medicare’s prescription drug spending. Washington, DC, Sep 15, 2010. Available from: https://www.cbo.gov/publication/21800. Accessed Dec 16, 2016.
  4. 4.↵
    1. Teng M,
    2. Khoo AL,
    3. Zhao YJ,
    4. et al
    . Meta-analysis of the effectiveness of esomeprazole in gastroesophageal reflux disease and Helicobacter pylori infection. J Clin Pharm Ther 2015;40:368–375.
    OpenUrlCrossRefPubMed
  5. 5.↵
    1. McDonagh MS,
    2. Carson S,
    3. Thakurta S
    . Drug class review: Proton pump inhibitors: Final report update 5. Portland, OR: Oregon Health & Science University; May 2009. Available from: https://www.ncbi.nlm.nih.gov/books/NBK47260/.
  6. 6.↵
    1. Gastala NM,
    2. Wingrove P,
    3. Gaglioti A,
    4. Petterson S,
    5. Bazemore A
    . Medicare Part D: Patients bear the cost of ‘me too’ brand-name drugs. Health Affairs 2016;35:1237–1240.
    OpenUrlAbstract/FREE Full Text
  7. 7.↵
    Good Stewardship Working Group. The “top 5” lists in primary care: Meeting the responsibility of professionalism. Arch Intern Med 2011;171:1385–1390.
    OpenUrlCrossRefPubMed
  8. 8.↵
    Choosing Wisely: An initiative of the ABIM foundation. Philadelphia, PA. Available from: http://www.choosingwisely.org. Dec 16, 2016.
  9. 9.↵
    1. Kesselheim AS,
    2. Avorn J,
    3. Sarpatwari A
    . The high cost of prescription drugs in the Unites States origins and prospects for reform. JAMA 2016;316:858–871.
    OpenUrlCrossRefPubMed
PreviousNext
Back to top

In this issue

The Journal of the American Board of Family     Medicine: 30 (6)
The Journal of the American Board of Family Medicine
Vol. 30, Issue 6
November-December 2017
  • Table of Contents
  • Table of Contents (PDF)
  • Cover (PDF)
  • Index by author
Print
Download PDF
Article Alerts
Sign In to Email Alerts with your Email Address
Email Article

Thank you for your interest in spreading the word on American Board of Family Medicine.

NOTE: We only request your email address so that the person you are recommending the page to knows that you wanted them to see it, and that it is not junk mail. We do not capture any email address.

Enter multiple addresses on separate lines or separate them with commas.
Using Drug Prescribing Patterns to Identify Stewards of Cost-Conscious Care
(Your Name) has sent you a message from American Board of Family Medicine
(Your Name) thought you would like to see the American Board of Family Medicine web site.
CAPTCHA
This question is for testing whether or not you are a human visitor and to prevent automated spam submissions.
17 + 1 =
Solve this simple math problem and enter the result. E.g. for 1+3, enter 4.
Citation Tools
Using Drug Prescribing Patterns to Identify Stewards of Cost-Conscious Care
Nicole Michele Gastala, Peter Wingrove, Winston Liaw, Stephen Petterson, Andrew Bazemore
The Journal of the American Board of Family Medicine Nov 2017, 30 (6) 824-827; DOI: 10.3122/jabfm.2017.06.170019

Citation Manager Formats

  • BibTeX
  • Bookends
  • EasyBib
  • EndNote (tagged)
  • EndNote 8 (xml)
  • Medlars
  • Mendeley
  • Papers
  • RefWorks Tagged
  • Ref Manager
  • RIS
  • Zotero
Share
Using Drug Prescribing Patterns to Identify Stewards of Cost-Conscious Care
Nicole Michele Gastala, Peter Wingrove, Winston Liaw, Stephen Petterson, Andrew Bazemore
The Journal of the American Board of Family Medicine Nov 2017, 30 (6) 824-827; DOI: 10.3122/jabfm.2017.06.170019
Twitter logo Facebook logo Mendeley logo
  • Tweet Widget
  • Facebook Like
  • Google Plus One

Jump to section

  • Article
    • Abstract
    • Methods
    • Results
    • Discussion
    • Appendix
    • Notes
    • References
  • Figures & Data
  • References
  • Info & Metrics
  • PDF

Related Articles

  • No related articles found.
  • PubMed
  • Google Scholar

Cited By...

  • Multiple Practical Facts and Ideas to Improve Family Medicine Care
  • Google Scholar

More in this TOC Section

  • Association of Social Needs with Diabetes Outcomes in an Older Population
  • Insurance Instability Among Community-Based Health Center Patients with Diabetes Post-Affordable Care Act Medicaid Expansion
  • Factors Influencing Changing Scopes of Practice Among Contemporary Graduates of the Nation’s Largest Family Medicine Residency
Show more Brief Reports

Similar Articles

Keywords

  • Medicare
  • Prescription Drugs
  • Stewards

Navigate

  • Home
  • Current Issue
  • Past Issues

Authors & Reviewers

  • Info For Authors
  • Info For Reviewers
  • Submit A Manuscript/Review

Other Services

  • Get Email Alerts
  • Classifieds
  • Reprints and Permissions

Other Resources

  • Forms
  • Contact Us
  • ABFM News

© 2025 American Board of Family Medicine

Powered by HighWire