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Science Policy Around the Web – January 11, 2019

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By: Mary Weston, Ph.D.

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Source: Wikimedia

A Virus Even More Dangerous Than Zika to Pregnant Women

According to a recently published paper, Rift Valley Fever Virus (RVFV), a mosquito-borne virus found in Africa and the Middle East, may be even more damaging to fetuses than the Zika virus.

RVFV largely affects livestock, causing death and 90%-100% abortions in cattle. In humans, RVFV infections cause anything from mild flulike symptoms to severe liver problems. In 2016, a study associated the development of RVFV infection while pregnant with an increased likehood of miscarriage, but nothing further was known. However, a new study published last month in Science Advances shows that RVFV may severely harm human fetuses if contracted by women while pregnant.

The paper investigated how the virus affects pregnant rats, finding that 40% more pups died compared to uninfected controls and all surviving offspring contracted the virus. Further, the infected mothers’ placentas contained more virus than any other tissue. Upon testing human placenta tissue, they discovered that RVFV infects specialized cells that supports the region of the placenta where nutrients flow in, an area typically resistant to viral infections. According to the Dr. Amy Hartman, the infectious disease specialist at University of Pittsburgh who led the study, “Zika must take the ‘side roads’ into the placenta to infect a fetus, while the Rift Valley fever virus can take the ‘expressway.’”

Given that RVFV is carried by the same mosquitos found in Europe and America, there is a risk the virus could spread beyond Africa and the Middle East. Currently, there are no human vaccines or treatment for Rift Valley Fever and the World Health Organization has classified the disease as a potential public health emergency. Last week, the Coalition for Epidemic Preparedness Innovations launched a call for proposals to develop human vaccines against RVFV and Chikungunya virus, providing $48 million to finance up to eight projects

(Emily Baumgaertner, New York Times)

 

Prescription Drug Costs Driven By Manufacturer Price Hikes, Not Innovation

A new report published in Health Affairs argues that the rampant cost increase of many prescription drugs in the US is primarily due to price inflation, not the entry of new products or improvements to existing therapies.

The study compared pharmacy claims from the University of Pittsburgh Medical Center Health Plan and pricing data from First Databank, a company that collects prescription drug sales data, over the period of 2008-16. They found that the average costs of brand-name oral drugs annually increased 9.2%, while brand-name injectable drugs increased an average of 15.1% every year, five to 8 times the rate of general inflation. For example, the Health Care Cost Institute cited that the cost of insulin doubled from 2012-16.

The costs of generics and specialty drugs also increased during these time periods, but the authors determined that was due primarily to new product entry. During 2008-16, many blockbuster brand-name medications, such as Lipitor, lost their patent protection. There is typically lag time between becoming a generic and the time required to file generic applications. Thus, initial prices of generics are more closely matched with brand-name prices until more competition enters the marketplace, which factored into the report’s observed increase in generic pricing.

William Shrank, the chief medical officer of the UPMC Health Plan and an author on the study, argues that since rising costs are not improving treatments, policy makers may want to get involved. “This observation supports policy efforts designed to control health care spending by capping price inflation to some reasonable level,” he says.

Total US spending on prescription drugsin 2017 was $333 billion, a 0.4% increase from 2016, but a 41% increase compared to $236 billion in 2007. Additionally, according to a 2017 Commonwealth Fund study, US residents pay more for medications than any other high-income countries. Recently, efforts towards lowering/regulating prescription drug costs has received bipartisan support and this new report may help further those proposed regulations.

(Alison Kodjak,NPR)

 

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Written by sciencepolicyforall

January 11, 2019 at 4:44 pm

Pharmaceutical Detailing: in the US the Details are Tied the Prescriber’s Name

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By: Allison Dennis B.S.

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Source: pixabay

While U.S. privacy laws protect patients from direct pharmaceutical marketing and shield their personal information from data mining, physicians are routinely identified based on their prescribing habits and targeted by pharmaceutical companies through personalized marketing campaigns. By their very nature, these campaigns aim to influence the behavior of prescribers. In other countries, including those protected by the European Union’s Data Protection Act, the personal identification of prescribers through medical data is strictly forbidden. However, in the U.S. these personalized campaigns are made possible by a robust pipeline of data sharing.

The pipeline begins with pharmacies, who routinely sell data derived from the vast volume of prescriptions they handle. While the prescribers’ names are usually redacted, IMS Health, a key health information organization in the pipeline, can easily use the American Medical Association (AMA)-licensed Physician Masterfile to reassociate physician ID numbers with the redacted names. The physician ID numbers are issued by the U.S. Drug Enforcement Administration (DEA) and are sold to AMA through a subscription service. IMS Health uses the prescription data to develop analytic tools for sale to pharmaceutical companies desperate to gain a marketing edge with individual prescribers. The tools consolidate the activity of nurse practitioners, dentists, chiropractors, and any professionals who can legally file a prescription. Marketers can use these tools to determine how much each named physician is prescribing, how that compares to other named physicians, what their specialty is, etc.

The data contained in the AMA’s Physician Masterfile is applicable for informing research and conducting surveys of practicing physicians, yet the need to identify physicians by name is usually not needed for public health research and enables prescriber manipulation.  The prescriber reports compiled by IMS Health enable pharmaceutical companies to take a data-driven approach to direct-to-physician advertising, a practice known as detailing. During a 17-month period between 2013 and 2015, pharmaceutical companies reported spending $3.5 billion in payments to physicians covering promotional speaking, consulting, meals, travel, and royalties. While many of the expenditures may be tied to legitimate collaborations between pharmaceutical companies and medical professionals, the U.S. Department of Health and Human Services warns that free samples, sham consulting agreements, subsidized trips, and industry-sponsored continuing education opportunities are all tools used by vendors to buy medically irrelevant loyalty. Indeed, physicians themselves seem conflicted over the significance of these relationships. When residents were asked if contact with pharmaceutical representatives influenced their prescribing practices, 61% believed they were unaffected. However, the same residents felt that only 16% of their peers were similarly immune to contact with pharmaceutical representatives.

Studies examining the role of detailing  have found it associated with higher prescribing frequency, higher costs, and lower prescribing quality, all with no contrasting favorable associations. Recent concerns over conflicts  of  interest arising from increased exposure of physicians to detailers led several academic medical centers to restrict sales visits and gift giving and implement enforcement mechanisms. Compared to hospitals with no detailing limitations, hospitals with limitations underwent an 8.7% relative decrease in the market share of detailed drugs and a 5.6% relative increase in the market share of non-detailed drugs. Overuse of brand-name drugs, which are most commonly associated with detailing, cost the US approximately $73 billion between 2010 and 2012, one-third of which was shouldered by patients. Advocates of the practice lament the lack of formal academic opportunities for physicians to learn about new drugs, believing the educational materials provided by pharmaceutical representatives fulfills a need.

The most tragic example of the potential harms of detailing targeting individual prescribers comes from the early days of the prescription opioid crisis. Purdue Pharma, the maker of OxyContin, used prescriber databases to identify the most frequent and least discriminate prescribers of opioids. Sales representatives, enticed by a bonus system that tracked their success according to upswings captured in the prescriber database, showered their target prescribers with gifts while systematically underrepresenting the risk of addiction and abuse from OxyContin. Recruitment into Purdue’s national speaker bureau and subsequent paid opportunities were further used to entice lukewarm and influential prescribers.

The last decade has seen several attempts to address the influence of detailing at the institutional, professional, and executive levels. Individual hospitals have begun limiting the access of physicians to vendors. The American Medical Student Association began issuing a conflict-of-interest scorecard, allowing all U.S. medical schools to track and assess their own detail-related policies, including those related to the limiting of gifts from the industry, industry-sponsored promotional speaking relationships, permitted accesses of pharmaceutical sales representatives, and overall enforcement and sanction of these policies. In 2016, 174 institutions participated. The AMA, which licenses the list of physician names used by health information organizations companies, has offered physicians the chance to block pharmaceutical representatives and their immediate supervisors from accessing their prescribing data. However, the Physician Data Restriction Program does not limit the ability of other employees at a pharmaceutical company to access prescribing data of doctors who have opted out. Physicians must renew their request to opt out every three years and are automatically added to the Masterfile upon entering medical school. Five years after the program’s introduction in 2006, just 4% of practicing physicians listed on the file had opted out.

In 2007, the state of Vermont outlawed the practice of selling prescription data for pharmaceutical marketing without prescriber consent. The law was quickly challenged by IMS Health, the Pharmaceutical Research and Manufacturers of America, and other data aggregators and eventually struck down by the U.S. Supreme Court. Vermont legislators held that detailing compromises clinical decision making and professionalism and increases health care costs and argued that the law was needed to protect vulnerable and unaware physicians. However, the Court held that speech in the aid of pharmaceutical marketing is protected under the First Amendment and could not be discriminately limited by Vermont law.

Congress made the first federal attempt to address the issue by enacting the Physician Payment Sunshine Act in 2010, which required companies participating in Medicare, Medicaid, and the State Children’s Health Insurance Program markets to track and collect their financial relationships with physicians and teaching hospitals. The transparency gained from the disclosures have allowed many researchers to systematically evaluate connections between conflicts of interests and prescribing behavior.

As policy makers and private watchdogs scramble to address the issues of detailing, the availability of physician names and prescription habits continues to facilitate the implementation of novel tactics. Limits on face time have pushed detailers to tap into the time physicians are spending online. When the names of prescribers are known, following and connecting with prescribers through social media accounts is straightforward. Companies like Peerin have emerged, which analyze prescriber Twitter conversations to learn whose conversations are most likely to be influential and which prescribers are connected. LinkedIn, Facebook, and Twitter all offer the ability to target a list of people by name or e-mail address for advertising. While all online drug ads are limited by the U.S. Food and Drug Administration, pharmaceutical companies are experimenting with the use of unbranded awareness campaigns to circumvent direct-to-consumer regulations.

While personalized prescriber marketing campaigns may be turning a new corner in the internet age, a simple opportunity exists at the federal level to de-personalize the practice of physician detailing. It is unclear the extent that the DEA stands to gain from selling physician ID subscriptions. However, in context of the downstream costs of the overuse of name-brand drugs this may be an appropriate loss. The U.S. Government’s central role in the reassociation of prescribers’ prescriptions could be directly addressed through systematic implementation of revised policy in order to preempt downstream prescriber manipulation.

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Written by sciencepolicyforall

November 9, 2017 at 10:41 pm

Science Policy Around the Web – December 23, 2016

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By: Joel Adu-Brimpong, BS

Source: Flickr, by Ben Gordon, under Creative Commons

Public Health

Looking Beyond Flint

All eyes turned to the city of Flint, Michigan as it burst onto the national scene after reports revealed that children were being exposed to dangerously high levels of lead in their drinking waters. Although shocking, a recent study shows that the Flint narrative is no abnormality. “In fact, it doesn’t even rank among the most dangerous lead hotspots in America,” states Reuters, an international news agency and investigative body that conducted the study.

In this Reuters report, it was discovered that almost 3000 areas in the country had at least twice the lead poisoning rates of the infamous Michigan city, with much less press coverage. In some areas, such as Baltimore, Cleveland and Philadelphia, areas with multigenerational lead poisoning, about 40 to 50 percent of children had elevated levels of lead. Nationwide estimates by the Centers for Disease Control and Prevention (CDC) purport that approximately 2.5 percent of small children, children between ages one and five, present highest levels.

For this study, Reuters obtained lead poisoning data from state health departments and the CDC. But rather than peruse and detail state or county-level data, Reuters pursued more granular results; testing for lead poisoning at the neighborhood-level. Altogether, Reuters observed 2,606 census tracts, or small county subdivisions, and 278 zip codes across the country with at least twice the prevalence rate of lead poisoning as Flint. It was noted that while poverty remains an integral predictor of lead poisoning, victims span the American tapestry of rich and poor, urban and rural and black and white.

Federal aid to assist states in lead poisoning management is quite limited. After the Flint debacle, Congress delivered $170 million in aid to Flint. However, the budget allocated to the CDC to assist states in lead poisoning control is only a fraction of the Flint package. With the 21st Century Cures Act set to withdraw approximately 3.5 billion from the Prevention and Public Health Fund, a fund established under Obamacare, and a pervasive political rhetoric regarding the repeal of Obamacare, lead poisoning may return to its obscure position in the public sphere. (M.B. Pell and Joshua Schneyer, Reuters)

Drug Policy

When Drug Prices Rise, Americans Turn Outward?

A recent study revealed that 70 percent of Americans take at least one prescription drug a day. And if you are among this group, or care for someone on medication, you are most likely aware that drug prices have been rising. In fact, a 2015 poll by the Kaiser Family Foundation (KFF) found that roughly 80 percent of Americans deemed costs of prescription drugs ‘unreasonable.’ A report by the IMS Institute for Healthcare Informatics earlier this year indicated that, after accounting for estimated reimbursements, net medication spending for the 2015 year was roughly $310 billion. So what happens when drug prices exceed affordability in the U.S.?

A poll by KFF last month found eight percent of survey respondents, or roughly 19 million adults in the U.S., had or knew someone in their household who had imported a drug at some point. Drug prices when obtained outside the country (i.e., Canada, Mexico, etc.) may be half the sticker price in the U.S., or even cheaper. This finding comes on the heels of recent spikes in prescription drug prices such as that of Daraprim, a life-saving drug often prescribed for AIDS patients, Cycloserine, a drug used to treat tuberculosis, Epipen, an injection device for patients with severe allergies, and others which have caused national outrage.

Although illegal for Americans, in most instances, to import drugs into the U.S. for personal use due to safety and effectiveness concerns, experts contend that eight percent is a conservative number. Some respondents may be reluctant to report violations of the law or are uncomfortable with talking about daily struggles with drug affordability. Demographics of individuals who imported prescription drugs ranged from young adults in college to elderly retirees, with prescription drugs imported spanning treatments for chronic and acute conditions.

Earlier this week, Senate Democrats sent a letter to Donald Trump urging the President-elect to effect bipartisan support to curb rising drug prices. But with no assurances in sight to curtail the epidemic of rising drug costs, will even more Americans turn outward in order to meet their prescription needs? If so, how might this affect the quality of circulating drugs and medication adherence practices? (Rachel Bluth, Kaiser Health News)

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Written by sciencepolicyforall

December 23, 2016 at 9:00 am