The Medical-Industrial Complex by zhangyun

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									The Medical-Industrial
     Complex
   Large & growing network of private & public
    corporations in the business of medical care &
    products for profit

   Includes proprietary hospitals & nursing homes,
    home care services, diagnostic services,
    hemodialysis, pharmaceutical co‟s, medical tools
    & technology supply co‟s
                  Drug Use

   Pharmaceuticals – 10.8 billion $‟s (1996)
    equates to 14.4% of total health
    expenditures



   Majority of Canadians have some coverage
    for prescription drugs
   Aboriginals & veterans are coverd by the
    fed got

   Most drug expenditures are for
    prescription drugs
    Socio-demographic characteristics
      Rates of Drug Use & Patient
     Variables: Age, Gender, & Class
   Drugs are frequently over-prescribed

   1/3-2/3 of antibiotics are unnecessary or
    inappropriate

   5-23% of hospital admissions result of
    drug-related illnesses
   Vulnerable – elderly (200 000 illnesses)

   Women – over or misprescribed
    psychotropic drugs or sedatives

   3:2 ratio females to males for
    psychoactive drugs
   65+ comprise 12% of pop & use 40% of
    drugs

   Only 19% use no prescription or over the
    counter drugs

   Multiple drug use increases as Canadians
    age
   ¼ of inappropriate drug use due to 2 Dr‟s

   Costs Canadian economy 3.5-4.5 billion $‟s

   if indirect costs included 7-9 billion $‟s

   Multiple drug use assoc w/ stress, lack of
    support & illness
   Drug interactions can affect absorption
    rate, distribution, elimination

   Drug effects different for elderly

   Drugs tested & prescribed for avg 30 yr
    old male
   77% of elderly admissions may result from
    overdose or side-effects

   Over-the-counter drugs may compound
    problems

   70% take w/out consulting physician
   Medication errors: forget to take; wrong
    dose; medication for wrong reason; can‟t
    read label; can‟t open container; impaired
    memory

   Results in: falls, dizziness, illnesses &
    death
   Drug use will increase due to:
   1)65+ yrs are increasing

   2)ratio of physicians to pop is increasing

   3)ratio of pharmacists to pop is increasing
   Women heavier prescription drug users
    than men except in regard to diagnostic &
    treatment drugs for HD



   More attention being paid to diagnosing
    HD in women
   Even w/ the intro of drug plans, low
    income drug expenditure 2x as high as hi
    income group

   Research suggests low income, less
    education families more likely to be
    prescribed mood altering drugs
        Physicians & Prescribing

   Dr‟s w/higher rates of prescribing: males,
    GP‟s, isolated practitioners, solo practice,
    from certain medical schools

   Up to a ¼ of Dr‟s aren‟t knowledgeable
    about drugs, eg antibiotics
   Dr‟s say they aren‟t influenced by
    commercialism

   Study: 70% of Dr.‟s supported
    commercialized drugs even though
    scientific data opposed claims
   Ideal prescribing: maximizing
    effectiveness, minimizing risks, minimizing
    costs & respecting patient choice

   Inappropriate prescribing: 17-43%
   2007 CMAJ
   Dr‟s more likely to misprescribe were:
   Those who had been in practice longer
   International medical graduates
   Hi volume practices
   Due to:
   1)lack of knowledge

   2)practice patterns

   5000 drugs available yet 50% of Dr‟s use
    27 of them
   The more frequently Dr‟s saw drug sales
    reps:
   A)the more likely to use that drug even if
    not best choice

   B)more often supported a commercial
    view of the drug
   C)more likely to prescribe antibiotics
    inappropriately

   D)less likely to prescribe generically

   E)more likely to use expensive vs equally
    effective cheaper drugs
   2004 BC study

   73% of Can Dr‟s couldn‟t estimate cost of
    orders (eg drugs, lab tests) to patients
    within 25% of actual cost

   Wild guessing
   28% of Dr‟s say they learn medication info
    from drug firms

   Expenditures by drug companies on
    promotion & advertising is 2x as much
    than on research & development
   Another major info source is Compendium
    of Pharmaceuticals & Specialties (CPS)

   It is inadequate: not comprehensive;
    recommends drugs w/ known destructive
    side effects, etc

   46% of drugs listed useless or obsolete
   CMA publishes “Drugs of Choice”

   1st & 2nd line drug therapies for 100‟s of
    clinical conditions
   Clinical decision support systems
   A well designed & well programmed
    computer system can help Dr‟s reduce
    errors, misdiagnoses, & unmet needs
   Younger physicians w/ more yrs of
    postgraduate education may have more
    appropriate prescribing practices

   Colleague-dependent practices have more
    effective prescribing habits
   Dr‟s who spend more time w/ patients
    prescribe more medication
                Pharmacists
   Have influence over Dr‟s & individuals

   Recommendations based on:
   Price: prices of 15 most common drug‟s
    cost varied up to 89%

   Pharmaceutical company influence: profit
    important
   Pharmacists can dispense any brand
    unless „no substitution” is written

   Pharmaceutical co‟s may discount price

   Discount pricing affects provincial
    revenues
    The Pharmaceutical Industry

   Drug industry: domestically owned &
    foreign owned

   90% of Can market are subsidiaries of
    multinationals belonging to the
    Pharmaceutical Manufacturers Assoc of
    Canada
   Can. is becoming more reliant on drugs
    developed & manufactured abroad
   Benefits of research & development are
    increasingly occurring outside of Canada
   Govt has leverage w/ pharmaceutical co‟s
    in controlling costs
   Pharmaceutical industry is one of the
    more profitable manufacturing activities
   Mergers
   Confusion for health care workers

   Use & profitability of drugs continues to
    increase due to:
   1)absence of price competition

   Selling price doesn‟t reflect prod cost

   Seems especially so in Canada
   2)patent protection
   Limit competition for a # of yrs
   Claims it allows to pay for research necessary to
    develop new drugs
   $802 million to develop a new drug (disputed,
    but not accurate # has been given)
   Yet most drugs are imitative
   3)competition & drug development focused on
    drugs w/ widespread potential for use

   Rare diseases not focused on

   20 000 pharmaceutical products based on only
    700 active ingredients

   36% of new drugs approved btwn „94-04 were
    new chemical entities
   4)production of brand-name rather than
    generic products

   Generics cost considerably less

   Pharmacists can substitute, but not as
    many available
   5)drug distribution (dumping) in
    developing countries

   Dumping of out-of-date drugs

   Health destroying side-effects
   Sometimes drugs marketed for a wide
    variety of symptoms – only appropriate for
    limited purposes
   3 categories of pharmaceuticals
   A)in-patent drugs

   B)out-of-patent & generic drugs

   C)over-the-counter drugs
   Developing countries often can‟t afford
    lifesaving drugs

   Eg protease inhibitors for HIV/AIDS
   Besides lack of availability

   Inappropriate use: lack directions, foreign
    language, illiterate, need water

   Regulatory authorities differ which may
    allow drugs which have been unapproved,
    banned or withdrawn
   5% of less developed countries have
    effective drug regulatory administration
   Even in developed countries there may be issues
    – try to get patented drugs approved as quickly
    as possible

   Dalkon Shield IUD

   Major problems

   Offered to developing countries at 48% of the
    cost
   6)provide select information to Dr‟s &
    consumers about the efficiency & safety of
    various drugs

   Can. Drug co‟s invest approx $10 000
    per/Dr.
   Advertise in a manner seen as educating
    the Dr.

   Contacts are systematic & persistent:
    include perks
   Promotional dinners result in 80%
    increase in sales of promoted drug

   Drug industry spends $2.1 billion annually
    in Canada
   Concern that there will be a conflict of
    interest

   Physicians & the Pharmaceutical Industry
    policy

   Enforcement of code problematic
   Profits over safety

   Eg Thalidomide

   Resulted in over 100 Can. Babies with
    phocomelia
   West German co.

   Recommended for respiratory infections,
    colds, coughs, flue, nervousness, &
    neuralgic & migraine headaches

   Widely available w/out a prescription
   Later marketed as a very safe sleeping pill

   Marketed as very safe

   5 yrs after its release serious side effects
    on the central nervous system were
    indicated
   Marketed in Canada as Kevadon (# of names) in
    1961 w/ warning of peripheral neuritis

   A few months later Germany reported to Ottawa
    birth defects

   Many pharmacists unaware that certain drugs
    contained thalidomide
   115 babies w/ phocomelia

   Also small ears, eye defects, depressed
    noses, facial tumours, missing organs,
    cardiovascular & intestinal tract problems

   Emotional trauma
   US had very few cases

   Dr. Frances Kelsey resisted distribution of
    the drug
   “Broken Promises” – documentary

   Drug safe for pregnant women

   Profited: pharmaceutical co‟s; pharmacists; Dr‟s;
    prosthesis manufacturer‟s

   Can govt criticized for not providing
    compensation
   Also cause ill health through toxins from
    plants

   Environmental damage
       Issues in Drug Regulation
   Most govt regulations are inadequate resulting
    in:
   1)1/2 drugs on market have never passed
    modern tests for safety or effectiveness

   CMA 2003 recommended post-marketing
    surveillance to monitor the ongoing safety of
    marketed drugs
   2)substandard drugs are being marketed
    & distributed overseas

   3)drug co‟s seem to have monopoly on
    info avail. to Dr‟s
   Govt cannot guarantee that any drug is safe for
    all uses it may be prescribed

   People regulate drug use ignoring directions or
    advice

   CMA 2003 found only 50% patients comply
    w/longterm drug therapy (less comply w/
    lifestyle alterations)
   Drug interactions not always accounted
    for

   Alcohol can have adverse effects
   Most drugs are developed & tested
    elsewhere

   May involve biased information

   Can drug laws are among the strictest
   However, Health Protection Board, the
    international pharmaceutical industry &
    the Pharmaceutical Manufacturing Assoc
    of Canada all have close ties
    Medical Devices & Bioengineering

   Medical device companies are among the
    largest growth industries in the world

   Artificial limbs, artificial heart valves,
    surgical equipment, etc
   Regulations controlling the industry are
    uneven

   Death and injury are consequences of
    faulty technology and equip.

   Early 80‟s 200 deaths/yr due to faulty
    anaesthesia equip
   The govt doesn‟t require evidence of
    potential harm or safety of equp

   Exceptions: tampons, condoms, contact
    lenses & devices implanted for more than
    30 days in the body
   Industry expected to police itself

   Inadequate

   up to 50% of medical devices delivered to
    hospitals fail to meet minimum standards
    for safety established by independent
    Canadian Standards Assoc

								
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