Improving drug prescribing in a primary care practice. Improving drug-therapy decisions through educational outreach. A randomized controlled trial of academically based "detailing". Effect of fundholding and indicative prescribing schemes on general practitioners' prescribing costs. The effect of a copay increase on pharmaceutical utilization, expenditures, and treatment continuation. The impact of implementing a more restrictive prescription limit on Medicaid recipients. Effects on cost, therapy, and out-of-pocket expenditures. The medical office of the 21st century (MOXXI): effectiveness of computerized decision-making support in reducing inappropriate prescribing in primary care. Cost effectiveness of two interventions for reducing outpatient prescribing costs. The influence of an academic representative on prescribing by general practitioners. GP fundholding and prescribing in UK general practice: evidence from two rural, English Family Health Services Authorities.
A model for improving physician prescribing that utilizes computerized feedback was studied in a family medicine residency practice. Resident and faculty physicians were stratified by level of experience and randomized into two groups. For 9 months the experimental group received monthly printouts identifying drugs they had prescribed by brand name with estimates of cost savings that might have been realized by prescribing generic drugs. The control group received no feedback. Prescription monitoring of both groups continued for 12 months after all feedback had ceased. Median weighted rates of generic prescribing for the experimental physicians were 14% for the baseline, 67% for the feedback, and 54% for the follow-up periods. Rates for the control physicians for the three periods were 32%, 37% and 31%, respectively. The increase in generic prescribing by physicians in the experimental group was significantly greater than for control physicians (P = 0.01). The feedback model improved rates of generic prescribing but should be evaluated for broader areas of physician prescribing. Improving precision and economy in the prescribing of drugs is a goal whose importance has increased with the proliferation of new and potent agents and with growing economic pressures to contain health-care costs. We implemented an office-based physician education program to reduce the excessive use of three drug groups: cerebral and peripheral vasodilators, an oral cephalosporin, and propoxyphene. A four-state sample of 435 prescribers of these drugs was identified through Medicaid records and randomly assigned to one of three groups. Physicians who were offered personal educational visits by clinical pharmacists along with a series of mailed "unadvertisements" reduced their prescribing of the target drugs by 14 per cent as compared with controls (P = 0.0001). A comparable reduction in the number of dollars reimbursed for these drugs was also seen between the two groups, resulting in substantial cost savings. No such change was seen in physicians who received mailed print materials only. The effect persisted for at least nine months after the start of the intervention, and no significant increase in the use of expensive substitute drugs was found. Academically based "detailing" may represent a useful and cost-effective way to improve the quality of drug-therapy decisions and reduce unnecessary expenditures. To compare general practitioners' prescribing costs in fundholding and non-fundholding practices before and after implementation of the NHS reforms in April 1991.
                Analysis of prescribing and cost information (PACT data; levels 2 and 3) over two six month periods in 1991 and 1992.
                Oxford region.
                Three dispensing fundholding practices; five non-dispensing fundholding practices; and seven non-dispensing, non-fundholding practices.
                Percentage change in net cost of ingredients, number of items prescribed, average cost per item, and proportion of generic drugs prescribed after NHS reforms.
                Prescribing costs increased in all practices in the six months after the reforms. The net costs of ingredients increased among dispensing fundholders by 10.2%, among non-dispensing fundholders by 13.2%, and among non-fundholders by 18.7%. The number of items prescribed also increased in all three groups (by 5.2%, 7.5%, and 6.1% respectively). The increase in average cost per item was 4.8% for dispensing fundholders, 5.3% for non-dispensing fundholders, and 11.9% for non-fundholders. Dispensing fundholders increased the proportion of generic drugs prescribed from 26.9% to 34.5% and non-dispensing fundholders from 44.5% to 48.7%; non-fundholders showed no change (47%). Five of the eight fundholding practices made savings in their drugs budgets at the end of the first year of fundholding (range 2.9-10.7%; the three other practices overspent by up to 3.6%). All non-fundholding practices exceeded their indicative prescribing amounts (range 3.2-20.0%).
                Fundholding has helped to curb increases in prescribing costs, even among dispensing general practitioners, for whom the incentives are different. Indicative prescribing amounts for non-fundholding practices do not seem to have had the same effect. No research has evaluated the impact of an increase to a copay that is reflective of today's healthcare market. This study examined the effect of an increase from a $10 to $15 copay for brand drugs on key pharmaceutical utilization measures, including participation rates, treatment continuation, and expenditures, in an adult population.
                A quasi-experimental, pre-post design with control group was used.
                Two different employer plans implemented an increase from $10 to $15 for brand copays in January of 1997. The utilization and expenditures of these plans were compared with those of a control group with a constant brand copay of $10 for 6 months preceding and 6 months following the copay increase.
                When other predictor variables were controlled for, the copay increase was not associated with a statistically significant difference in overall utilization compared with the control group, although brand utilization was significantly lower in the copay group. Savings to the payer were substantial, and resulted primarily from cost-shifting, reduction in brand utilization, and an increase in the generic fill rate. The rates of continuation with chronic medications in the 6 months following the copay increase were not reduced in the copay group compared with the control group.
                A copay increase can provide substantial savings to a payer without being a major deterrent to overall utilization or resulting in discontinuation of chronic medications. On November 1, 1991, the Georgia Department of Medical Assistance reduced the maximum number of monthly reimbursable prescriptions from six to five. This policy change provided a natural experiment to investigate the recipient responses to a decrease in an existing prescription limit. The research design was a quasiexperimental, retrospective, 12-month interrupted time-series analysis of a cohort. The cohort consisted of 743 ambulatory recipients who were high prescription users. Complete Medicaid claims data were obtained, in addition to pharmacy-generated computer profiles for all cohort recipients to determine Medicaid and out-of-pocket prescriptions expenditures. Interrupted time-series analyses were performed to model the effect of the five-prescription limit on total, Medicaid-reimbursed, out-of-pocket, and prescription use across eight therapeutic categories. After the implementation of the five-prescription limit, total prescription use fell 6.6%, prescriptions reimbursed by Medicaid fell 9.9%, and prescriptions paid for out-of-pocket increased 9.7%. Abrupt, permanent decreases were observed for cardiovascular, miscellaneous, pulmonary, and palliative therapeutic drug categories (alpha = 0.05), whereas gastrointestinal, chemotherapy, hormone (insulin), and central nervous system prescription use remained constant. The implementation of a more restrictive prescription limit alters prescription regimens potentially predisposing elderly Medicaid recipients to clinical consequences. Further examination of the health outcomes of these recipients is necessary. Adverse drug-related events are common in the elderly, and inappropriate prescribing is a preventable risk factor. Our objective was to determine whether inappropriate prescribing could be reduced when primary care physicians had computer-based access to information on all prescriptions dispensed and automated alerts for potential prescribing problems.
                We randomly assigned 107 primary care physicians with at least 100 patients aged 66 years and older (total 12 560) to a group receiving computerized decision-making support (CDS) or a control group. Physicians in the CDS group had access to information on current and past prescriptions through a dedicated computer link to the provincial seniors' drug-insurance program. When any of 159 clinically relevant prescribing problems were identified by the CDS software, the physician received an alert that identified the nature of the problem, possible consequences and alternative therapy. The rate of initiation and discontinuation of potentially inappropriate prescriptions was assessed over a 13-month period.
                In the 2 months before the study, 31.8% of the patients in the CDS group and 33.3% of those in the control group had at least 1 potentially inappropriate prescription. During the study the number of new potentially inappropriate prescriptions per 1000 visits was significantly lower (18%) in the CDS group than in the control group (relative rate [RR] 0.82, 95% confidence interval [CI] 0.69-0.98), but differences between the groups in the rate of discontinuation of potentially inappropriate prescriptions were significant only for therapeutic duplication by the study physician and another physician (RR 1.66, 95% CI 0.99-2.79) and drug interactions caused by prescriptions written by the study physician (RR 2.15, 95% CI 0.98-4.70).
                Computer-based access to complete drug profiles and alerts about potential prescribing problems reduces the rate of initiation of potentially inappropriate prescriptions but has a more selective effect on the discontinuation of such prescriptions. This prospective, randomized, controlled trial, based in a Veterans Administration Hospital general medicine clinic, compared the cost effectiveness of two behaviorally oriented interventions designed to reduce physicians' drug prescribing costs. Clinical pharmacists visited one group of 11 physicians during weekly clinic sessions to counterdetail the prescribing of certain targeted drugs. A second group of 10 physicians were given data each week comparing their individual prescribing costs to those of their colleagues (peer-comparison feedback). A control group of 10 physicians received neither intervention. Written patient-specific suggestions for cost-effective prescribing were employed in both intervention groups. Baseline prescribing costs were monitored through the hospital's computer during a three-month, preintervention period and a seven-month intervention period. The 2026 written suggestions made by the doctors of pharmacy resulted in 613 (30.3 percent) prescribing changes, including deletion, substitution, or change in dosage of targeted drugs. There were no intergroup differences in the response to written suggestions. However, the group receiving face-to-face visits from the clinical pharmacists achieved lower average prescription costs than the control group during seven of eight months. Intergroup differences were statistically significant (p less than 0.05) during three of the last five months of the study. The face-to-face meeting intervention was cost-effective, saving +478 per physician over seven months after accounting for Pharm.D. salary costs. There was no significant decrease in the number of prescriptions written by the face-to-face group compared with the control group, suggesting that drug substitution rather than deletion was the method used by physicians to lower drug costs. No savings resulted from the use of peer-comparison feedback. We conclude that personal visits by a Pharm.D. are a cost-effective technique for reducing physicians' prescribing costs, and are superior to peer-comparison feedback. 1. The effect of providing information about medicines by a short 'sales' interview between individual general practitioners and an 'academic representative' on prescribing was investigated. 2. The promotional campaign was designed to encourage a rational approach to prescribing of non-steroidal anti-inflammatory agents in an intervention group of 101 general practitioners selected at random from the Leeds Family Practitioner Committee (FPC). The remaining general practitioners in the Leeds FPC acted as a reference group. 3. The prescribing data for each group for 5 months immediately prior to and 5 months following intervention were compared. 4. Intervention produced a significant increase (P less than 0.005) in the prescribing cost of ibuprofen, the non-steroidal promoted as first choice agent, which was sustained for at least 5 months. 5. Prescribing of the second choice agent, piroxicam, decreased in the reference group but not in the intervention group. 6. There was a decrease in the average prescribing cost of pounds 6.60 per doctor per month in the intervention group compared with the reference group. Two separate prescribing budget regimes (part of GP fundholding and the indicative prescribing scheme) were introduced into UK general practice in April 1991 in an attempt to contain the growth in NHS expenditure on prescribed drugs.
                The aims of this study are (i) to examine whether the fundholding scheme has been more effective at containing prescribing cost growth than the indicative prescribing scheme and (ii) to ascertain whether its implementation, at a practice level, has been affected by local circumstances and conditions.
                Prescribing cost data were collected from two rural, English Family Health Services Authorities for the financial years 1990/1991 to 1993/1994. Exploratory analysis was performed using regression analysis and nonparametric statistical techniques.
                Initially, the fundholding scheme has been the more effective at containing expenditure on prescribed drugs. However, the implementation of the schemes in rural areas has probably been affected by the existence of practices with permission to dispense drugs to their own patients, due to a lack of pharmacies in such areas.
Based on the evidence in this review from three Western European countries, drug budgets for physicians in private practice can limit drug expenditure by limiting the volume of prescribed drugs, increasing the use of generic drugs or both. Since the majority of studies included were found to have serious limitations, these results should be interpreted with care.