When Prescriptions Change Behavior: Q&A with Danea Horn

Can access to prescription medications influence not just treatment, but lifestyle choices too?

Danea Horn, PhD, an associate professional researcher in the Clinical Pharmacy Department at UCSF’s Center for Translational and Policy Research on Precision Medicine (TRANSPERS), has explored a range of related questions, from how patients respond to a diagnosis to how drug pricing programs may unintentionally shape prescribing practices. Her work incorporates perspectives on behavioral economics, public policy, and patient-centered care.

We talked with Horn about the ripple effects of pharmaceutical innovation, the role of pharmacists in shaping health behaviors, and what her research could mean for the future of health policy.

Q: Your dissertation research looked at patient behavior related to cardiovascular disease. How did that come about?

A: I was fascinated by a theory put forth in the 1970s by economist Sam Peltzman, who studied what happened when seat belts were introduced in cars. He found that while seat belts were designed to make driving safer, they did not actually decrease car accident fatalities, because people drove faster and with more risky behavior.

I started to wonder if something similar could happen with medications. If someone is diagnosed with high blood pressure or high cholesterol and then starts a medication, do they ease up on lifestyle changes like improving their diet or exercising more?

I was able to explore this by looking at data from the Framingham Heart Study, which followed people over decades, tracking health behaviors and outcomes. What I found is that a diagnosis alone — irrespective of medication availability — led people to adopt heart-healthy behaviors. One notable exception was smoking behavior, which decreased in response to new prescription drugs coming to market in the 1970s. This may reflect more physician interaction, placing a greater emphasis of the harms of smoking, or that taking a pill every day was a reminder to adhere to more overall healthy behaviors.

Q: Another research project of yours looks at the 340B drug pricing program, which was developed in 1992 to support safety-net health care providers. Can you explain how this program works and what drew you to investigate its impact on patient care?

A: The 340B program was created to allow providers, such as disproportionate share hospitals and nonprofit clinics that serve uninsured or underinsured patients, to purchase outpatient medications at steep discounts, of 25 to 50 percent off, while being reimbursed at full price by insurers. Over the years, there has been a massive expansion in program participation due to expanded eligibility criteria and provisions in the Affordable Care Act, such that by 2022, more than 54,000 providers were enrolled.

What interested me was how this financial structure might shape treatment decisions. If a care institution benefits financially from prescribing certain medications, could that change the way individual providers deliver care? I wanted to see whether patients — specifically older Medicare beneficiaries diagnosed with breast cancer — receive different care when they’re treated by an oncologist who works for or is affiliated with a 340B participant.

I found that oncologists who join a 340B participating institution significantly increase the share of patients who receive pharmaceutical cancer treatment(s) and increase the intensity of prescribing. Despite the increased care, I found no change in the 1-year mortality or survival duration. It may be that the increased use of pharmaceutical cancer treatments in response to 340B is proving to be high value for some patients but low value for others, thereby creating offsetting impacts on survival. This raises the question: Is the 340B program promoting the best care, or just more care?

Q: In addition to what they are already doing, how else can pharmacists support patient outcomes?

A: Pharmacists can get involved in the risk/benefit conversation of medications by becoming more aware of clinical studies and guidelines. They can get to know their patients background, characteristics, and health status more so that, as pharmacists, they can talk with the doctor about benefits of treatment and be part of broader conversations about potential side effects, for example by understanding the other comorbidities that a patient could have. That may help reduce risk by some meaningful amount.

Q: What do you want policymakers to take away from your findings?

A: In regard to the 340B program, it is important to support safety net health care providers, particularly rural hospitals and under resourced hospitals, because there are a lot of patients that still have problems with access to care. But we need to reassess how we are supporting those providers in a way that does not inadvertently promote a specific sort of treatment.

Ultimately, we need to design systems that support whole-person care. Pharmacists, physicians, and clinicians need to be able to emphasize to patients that medications are an important part of treatment and can serve as a support for healthy behaviors, not necessarily a replacement. In general, we can recognize that a diagnosis is a pivotal point for patients, and we can provide them with more supports to make positive changes in their life, from medication adherence to other healthy behaviors.

Q: Where is your research headed next?

A: I’m turning my focus to FDA-expedited regulatory programs, which provide faster access to treatments for patients with severe conditions and unmet medical needs, but this speed comes at the cost of limited long-term safety and efficacy data. These programs were created because patients advocated for earlier access to medications with a willingness to accept uncertainty around benefits and risks. I am considering how stakeholders in the health care system make decisions with uncertainty under expedited regulatory approval. For example, under the FDA accelerated approval program, drugs often come to market with evidence of shorter-term benefits, such as progression free survival in cancer (the time a patient lives without their cancer getting worse) as opposed to overall survival which take more time to evaluate in clinical studies.

Q: Your connection to this work is personal?

A: Yes. I’m a kidney transplant recipient, so I rely on pharmaceuticals every day, and I know how life-changing they can be. I have deep gratitude for pharmacists and pharmaceutical developers.