The perils of problematic prescribing: A double dose of warnings

Two new reports from the CDC show the dangers of overprescribing narcotics and antibiotics. Is there a way for doctors and consumers to make better decisions?

Twice last week, the Centers for Disease Control and Prevention (CDC) has pointed to the harm caused by aberrant and inappropriate prescribing by physicians.

First, the CDC reported Monday that doctors are a primary source of narcotic painkillers for chronic abusers at the highest risk of overdoses. Physicians edged out even family, friends and drug dealers. More than 16,000 people died of narcotic overdoses in 2010, the most recent year for which data is available, the CDC has reported.

On Tuesday, the public health agency said that it found vast differences in the use of antibiotics among different hospitals’ medical/surgical wards. Doctors in some hospitals prescribed three times as many antibiotics as those in other hospitals. The CDC also said that in about one-third of cases, prescriptions for the antibiotic vancomycin included a potential error – either it was prescribed without proper tests or evaluation, or given for too long.

For more than a year, ProPublica also has been looking at physicians’ prescribing practices. Our reporting has showed striking differences in how doctors prescribe drugs, with some ordering massive quantities of risky or potentially inappropriate medications in Medicare’s prescription drug program. Despite collecting data on every prescription, the government has done little with the information. Our Prescriber Checkup tool allows the public to look up individual physicians and compare their drug choices in Medicare’s program, known as Part D, to others in the same specialty and state.

We talked to Dr. Thomas Frieden, the CDC’s director, to help put the agency’s two recent reports in context and to ask how doctors can compare their prescribing to their peers and what the role of consumers should be.

This conversation has been edited for length and clarity.

Q. The CDC issued two reports this week, on opioid abuse and antibiotic prescribing. While they’re not explicitly linked, there does seem to be a common thread between them, namely that inappropriate prescribing by physicians can cause patient harm. Do you agree?

A. I think I would frame it a little bit more broadly. I think although there are certainly many areas in health care where we’re under-medicating and not using enough medications, more commonly we’re overmedicating. I think you can see that in antibiotics, you can see it in opiates, you can see it in some of the psychoactive drugs. There’s an old saying called the “inverse care law,” and the inverse care law says that the people who need care the most get it the least and vice versa. It’s not about more or less treatment; it’s about better treatment.

Q. One problem I see is that doctors have no real way of knowing if their prescribing practices are aberrant compared to peers. Is there a way for them to benchmark their habits?

A. We are now recommending that every single hospital in the country have an antibiotic stewardship program, and that this program include at a minimum seven core elements. And those elements are leadership, accountability, drug expertise, tracking, reporting and educating. Reporting means regularly reporting to staff on prescribing and resistance patterns and steps to improve. An individual doctor may not be able to know, but a health care system or a hospital can provide feedback that compares each doctor and can identify one who is out of kilter with the rest.

Q. Certainly for in-hospital prescriptions, one can imagine that a hospital can do that. For outpatient prescriptions, for opiates for example, and for physicians who don’t work for a hospital system, how should it be done?

A. That’s harder. More and more physicians are part of large practices. I think that will make it easier. More and more electronic health records can have modules that can give feedback and information. One of the things that we have focused on is something called Million Hearts, preventing a million heart attacks and strokes in five years. One of the things we’ve learned from health care systems around the country that have done an effective job is that they give feedback to their physicians and other clinicians every month. If you give feedback once a year, you’re going to get progress over a decade. But if you give feedback every month, you can get substantial progress over a single year, and we’ve seen that over and over again. It’s also very important to involve entire teams. It’s not just about doctors.
It’s doctors, nurses, pharmacists, office managers, outreach workers. We’ll improve health care when we systematize our approach and use a team-based approach.

Q. Consumers likewise haven’t historically had a way to check their doctors’ prescribing against peers to know if they are going to a doctor who prescribes antibiotics more than peers or a doctor who is enabling abusers of narcotics. Should consumers have tools where they can go to check their physician and integrate that into their care decisions?

A. I don’t want to comment on that specific question, but as a general rule, transparency is good. And one of the things that we’ve learned in health is that when you provide transparent information on the performance of health care institutions, it affects the behavior of those institutions far more than you might have anticipated. And it does it not by changing patient behavior so much as changing institutional behaviors. Doctors went to medical school to help people and doctors got into medical school by being very competitive. And no doctor wants to find him or herself at the bottom of a list. What we have seen around the country is that when there are transparent rankings of facilities, they take them very seriously and they change and improve practices. As a general rule, transparency is important. I will say it’s possible to get this wrong if it’s not well done.

Q. When you talk about prescribing, you hear a lot from the physician community that attempts by the government to address overprescribing butt up against physician autonomy issues. What are the limits of a doctor’s right to prescribe what he or she wants?

A. First off, I think that’s a misguided critique. Because take antibiotic prescribing in hospitals. We’re not saying give less. We’re not saying tell doctors what to do and not to do. We’re not saying treat this way. We’re saying make explicit your reasoning and set up your protocol, as long as it’s evidence-based. What we’re basically saying is we need to reduce unwarranted variability. So, come up with an algorithm, come up with a protocol, and then stick to it unless you have a valid and documented reason to depart from it. I don’t think that undermines physician autonomy at all. I think that empowers doctors to make a considered evidence-based decision on what their policy will be as a general rule and then to increase the likelihood that that policy is followed for all of their patients.

Q. And what if that policy is not evidence-based?

A. That’s a problem. Let me take an example of tuberculosis treatment, which is an area I worked on for more than a decade. If you’re a private doctor and you decide you’re going to treat your patient with tuberculosis with nonstandard medications that may result in them developing drug resistance. You actually do not have that level of autonomy -- sorry. That really never happens because what we do is we work collegially with the American societies of infectious disease physicians and of pulmonologists, and we all agree on how tuberculosis patients should be treated. If an individual doctor is not doing that, we send an outreach worker out or a nurse out and we talk with the doctor quietly and privately. We provide them with the evidence and we explain this is the way that they can best treat their patients and avoid that patient developing a drug-resistant strain that might affect or infect other people.

Q. Anything else you’d like to add?

A. It would be very interesting to look at hypertension because, unlike the issues that you’re raising, this is an area where we are undermedicating. We face something called therapeutic inertia where doctors see a slight elevation of blood pressure and they say, “Come back in three months” and three months later, the patient doesn’t keep the appointment or they see another doctor. And ultimately we end up with only about half of Americans with high blood pressure having it under control, including people who’ve see their doctors twice in the past year. And that, if you step back and you say what single thing could you do in health care to save the most lives, it would be to better treat high blood pressure.






3 years ago


SEBI refuses to take note of price manipulation in Transgene Biotek – Part II

Did Transgene Biotek insiders use structured GDRs as an end game through price manipulation and motivated announcements? We will never know because SEBI refuses to investigate

On Monday, Moneylife pointed out, several shareholders of Hyderabad-based Transgene Biotek Ltd are crying foul () over the alleged misuse of global depository receipts (GDRs)—a financial instrument used to raise capital overseas, and several “well-timed” announcements by the company. However, market regulator Securities and Exchange Board of India (SEBI) is to yet even acknowledge several complaints filed by these shareholders.

Fall in promoters’ stake

The shareholding pattern of Transgene between June 2012 and September 2012 quarters reveal ‘precise’ share transactions between ‘related parties’. During these two quarters, custodian shareholding decreased to 39% from 73.44%, a difference of 34.44%. However, during the same period, public shareholding, including foreign institutional investors (FIIs), domestic institutional investors (DIIs) and non-institutions, increased significantly to 51.22% from 16.78% in June 2012, again a difference of 34.44%. So while custodian stakeholders were selling Transgene shares, the ‘public’ was buying exactly the same quantity.

 Share Holding Pattern

Jun - 2012

Sep - 2012

Dec - 2013

Promoter and Promoter Group




Indian Promoters




Foreign Promoters




Public (A+B+C)




A) Foreign Institutional Investors (FII)




B) Domestic Institutional Investors (DII)




C) Non Institutions









6.58 crore

6.58 crore

7.57 crore


Move forward to December 2013, and one can see the exit of FII and substantial stake sell by custodians. At the same time, public shareholding or stake hold by non-institutional investors increased to 70.04% at the end of December 2013 quarter, as per the data from BSE. Even, promoters seem to have increased their stake to 21.68% during the December 2013 quarter from less than 10% in September 2012.

The delisting ‘game’

Another interesting part is promoter or promoter group held 9.8% stake during September 2012 and yet citing lower share price tried to delist Transgene Biotek from stock exchanges. On 4 September 2012, Transgene board announced its decision to delist its shares. Three days later, it announced delisting price of over Rs25 per share as against the prevailing price of only Rs10.36 per share.

Shareholders allege that the company had deliberately announced its delisting at a price 2.5 times more than its prevailing share prices for manipulation. The company apparently sent postal ballots for getting approval from shareholders for delisting. However, there was no response from shareholders, the company said. The question here is after all, why will shareholders disapprove such a “generous” proposal? According to shareholders, either they received the postal ballots just one day prior to the deadline or never received any such thing.

One such shareholder in his complaint to SEBI has asked many questions on Transgene’s GDR issue as well as its price manipulative intentions behind delisting announcement. The shareholder in his complaint said, “We (shareholders) believe that the promoters did not have any intention of delisting the company in which they only hold 9.8% shares. If they were serious about their holding in the company, they would have increased their stake through creeping acquisition. If their co-investors were serious about taking a strategic stake in the company, they would have bought out the GDRs outstanding or made an open offer to buy out from public without the ‘delisting’ clause. The structured GDR is normally used as an end game by promoters, who hardly have any holding in the listed entity and are looking forward to milk whatever remains of their company and their reputation in the market place. The modus operandi is similar and operations are through a small clutch of entities which your intelligence wing can find out just by going through the bulk deals done in the small/ mid cap companies with low promoter holding which have also issued a GDR despite their poor financial performance.”

The promoter was holding 9.78% in company during September 2012 quarter, when it announced delisting at floor price of Rs25 per equity share.

Another investor in his complaint to the market regulator said, “We don't expect that SEBI, which has advanced monitoring and tracking mechanism, to miss such startling white collar crimes being done on investors. Since your systems haven't thrown up these irregularities, we (shareholders) are pointing it out. Please act now - no point ‘bolting the stable door after the horse is stolen’ and he further requested SEBI to investigate in this matter and turn a blind eye!”

The shareholding of promoters in the Transgene Biotek was just 9.77% during December 2012 and FII’s holding was 14.26%. As on December 2013, promoters’ shareholding increased to 21.68% and company now doesn’t have any FII holdings. It has declared losses too. During December 2013, the company made loss of Rs66.45 lakh, its sales stood at Rs24.58 lakh.

Although the shareholders are raising the GDR and share price manipulation issue of Transgene Biotek, SEBI, the market regulator, till date has not paid any heed to the complaints. This is surprising, as the same SEBI has put in place an Integrated Market Surveillance System (IMSS) to monitor market activities and had used this facility to curtail suspicious trading activities.

During September 2011, SEBI, the market regulator, restrained KII, a sub-account of Credo Capital Plc, from dealing with securities in the domestic market in the wake of its alleged involvement in manipulating GDRs.

SEBI had in 2009-10 received alerts regarding large scale off-market transactions in its IMSS system in shares of IKF Technologies, Cat Technologies, Avon Corporation, Asahi Infrastructure and K Sera Sera.

The regulator had prima facie found that KII among a few other entities was cancelling GDRs of companies and converting them into normal shares for sale in the Indian securities market, to a few selected counterparties.

Transgene Biotek closed Tuesday 3.5% down at Rs3.34 on BSE, while the 30-share Sensex ended the day marginally lower at 21,845.

You may also want to read…

SEBI refuses to take note of price manipulation in Transgene Biotek – Part I





3 years ago

Its common that sebi nor nse nor bse would take any steps to price manipulation because its the employees of sebi nse bse who instigate the directors quota of share to be manipulated by the brokers of their notice as nominated by sebi bse nse for which the brokers give the percentage to officials of sebi bse nse this going on for good olden days and our stock market would never improve and an stage would come when all people come to know about the maladministration of indian capital market they would desist from ivnesting in stock market as most of the funds in the stock market is funds of politicians and blackmoney holders and hawla traders where their money could be legalised even those funds which they say that comes from FII from maurties and maladives are not FII's own fund but the blackmoney of politician and industrialist go to maurities or maldaives and then renenter the india in form FII and as such our surmise no FII are interested in investing in india they knew about indian administration and how they loot is know so no investiment is made is our surmise

Bitcoin fallout: Mt Gox files for US bankruptcy protection

Besides protection of its assets, Mt Gox has requested the suspension of actions in the US that jeopardise its efforts to restructure abroad

Troubled Bitcoin exchange Mt Gox has filed for protection under US bankruptcy law, 10 days after doing the same in Japan after a huge loss of the digital currency, a court document showed.


The Japanese Exchange is now protected temporarily under Chapter 15 of US bankruptcy law for foreign firms.


A bankruptcy court in Dallas, Texas accepted the request and will make a definitive ruling in April, the document said.


Chapter 15 protects assets in the US of foreign firms facing insolvency procedures in their home countries.


Besides protection of its assets, the exchange has requested the suspension of actions in the US that jeopardise its efforts to restructure abroad, it said in its court filing.


Mt Gox faces a class action lawsuit filed 27th February in Illinois by an American named Gregory Greene. He cited deceitful and illegal actions by MtGox, according to a court document.


“With respect to the Chapter 15 bankruptcy proceedings, today was a big victory for Mt Gox’s victims. Mt Gox tried to have all US proceedings ‘stayed’ or frozen while it goes at its own pace in the Japanese bankruptcy,” Greene’s attorney Steven Woodrow said in an email to AFP.


“We are working with attorneys from around the globe who are planning on filing additional cases in the near future.”


Mt Gox Bitcoin exchange filed for bankruptcy on 28th February in Japan, CEO Mark Karpeles saying it had lost nearly half a billion dollars’ worth of the digital currency in a possible theft.


The company’s lawyer said 750,000 Bitcoins belonging to customers had gone, along with Mt Gox’s own store of the currency, which she said was around 100,000 units.


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