Surgical mortality, hospital quality, and small sample size

In Reply: We strongly endorse the use of direct generic substitution and “rational prescribing” when they are based on rigorous scientific information, because these are important ways to help people manage their drug expenditures. This is based on our own finding that seniors who exceeded their drug benefit caps decreased their use of essential medications, as well as on estimates from others that 1 in 4 Medicare beneficiaries will face the “donut hole” in the new Medicare drug benefit. This “donut hole” represents the gap in coverage when beneficiaries’ annual drug expenditures exceed their benefit cap but are not yet high enough to qualify for catastrophic coverage. Better mechanisms to help people manage their drug costs must be found. We thank Drs Bjarnason and Kampmann for highlighting these programs in Denmark. Currently, all 50 states in the United States allow pharmacists to make direct generic substitutions unless directly prohibited by clinicians on the prescription. We support the additional development of evidence-based guidelines that take into account cost as well as safety and effectiveness to help clinicians and patients choose medications. However, transparency to both the patient and the clinician regarding potential cost-effectiveness trade-offs is essential. In the United States, health plans, insurers, and pharmacy benefit managers often send information to clinicians and patients to increase their awareness of drug costs and effectiveness. Other sources such as the treatment guidelines from The Medical Letter on Drugs and Therapeutics and from the State of Oregon have also added cost information to independent comparisons of drug effectiveness and safety. Further work is needed to ensure consistency among these guides and to help patients and clinicians use these tools in daily practice so that a patient’s health is optimized at the price that he or she is willing to pay.