June 12, 2013
Madras case study details one clinic’s process of going pharma-free: “Small steps on the road to practice transformation”
Established in 2002, OHSU’s Oregon Rural Practice-based Research Network (ORPRN) seeks to improve the health of rural populations in Oregon by conducting and promoting health research in partnership with communities and practitioners.
Recently, one of its studies received some attention related to going pharma-free. The Journal of the American Board of Family Medicine published an article in its May-June 2013 issue discussing clinical research conducted in Madras, Ore., between 2005 and 2006 that ORPRN helped facilitate. The case study, about a practice going pharma-free, earned some publicity, including The Lund Report and the University of Washington School of Medicine.
The article’s lead author is David Evans, M.D., a family physician who practiced at the physician-owned Madras Medical Group (MMG) in central Oregon for 15 years. (Dr. Evans is now an assistant professor of family medicine at the University of Washington School of Medicine.)
Dr. Evans and colleagues in his practice group knew about evidence suggesting that the influence of pharmaceutical representatives and sample inventories of prescription medications produced negative effects on evidence-based care and increased costs.
In response to this evidence, the group initiated a policy to discontinue visits from pharmaceutical representatives and to stop accepting and distributing drug samples. In addition, the clinic removed anything with a drug name or pharmaceutical company logo on it including note pads, educational materials and coffee cups. The practice had to go out and buy new clocks.
In the journal article, Dr. Evans and colleagues concluded that changing practice culture to become a pharma-free clinic is achievable, but that considerable attention needs to be addressed across all levels of the practice – clinicians, staff and patients.
“The culture of doctors seeing drug reps in the office is ingrained in medicine,” said Dr. Evans. “We changed our practice culture with a thoughtful and deliberate process that gathered viewpoints of the whole clinic. Not much is known about this type of change and with ORPRN’s help and support we were able to share our experience.”
L.J. Fagnan, professor of family medicine and ORPRN director, noted it is unusual to find a family physician with the desire and perseverance to rigorously study and publish research that begins at the practice-level. The Madras partnership meshed well with ORPRN’s guiding principle. “As ORPRN responds to and develops clinician and practice questions, its practice-based research strives for a bottoms-up approach, from the clinician/practice to the academic researcher,” Dr. Fagnan explained.
Dr. Fagnan notes that a 2010 study of community-based primary care clinicians who participated in practice-based research network (PBRN) studies reported three needs correlated with clinician motivation:
- Competence – intellectual stimulation,“the physician as the critical scientist”
- Autonomy – enjoyment of research without the hassle of academic work-life
- Relatedness – PBRNs such as ORPRN as the antidote to the intellectual isolation associated with day-to-day primary care practice.
The Madras research also led to a related study headed up by Dan Hartung, PharmD, and colleagues (Haxby and Kramer) at the OSU College of Pharmacy, in collaboration with Dr. Evans, Dr. Fagnan, and Gabriel Andeen, M.D., (then a SoM MD student).
The study evaluated the effects of the pharma-free implementation on the prescribing patterns of MMG clinicians and found reductions in prescriptions for branded and promoted lipid-lowering and anti-depressant medication. [Hartung DM, Evans D, Haxby DG, Kraemer DF, Andeen G, Fagnan LJ. Effect of Drug Sample Removal on Prescribing in a Family Practice Clinic. Annals of Family Medicine. September/October 2010; 8: 402-409]
Through this research and many other projects, ORPRN has become a resource for disseminating best clinical practices and facilitating practice transformation throughout Oregon. “This is the type of work that demonstrates the value of collaboration between OHSU and community clinics in which the results yield significant benefits for Oregon’s rural practitioners and their patients,” said Dr. Fagnan.
Pictured above: L.J. Fagnan, M.D. (left), and David Evans, M.D.