Economic and Policy Analysis of University-based Drug “Detailing Improving drug-therapy decisions through educational outreach. A randomized controlled trial of academically based "detailing". Predictors of Physician Prescribing Change in an Educational Experiment to Improve Medication Use Cost Effectiveness of Two Interventions for Reducing Outpatient Prescribing Costs Adverse events associated with prescription drug cost-sharing among poor and elderly persons. The cost-effectiveness of tailored, postal feedback on general practitioners' prescribing of pharmacotherapies for alcohol dependence. Effectiveness of the Combination of Feedback and Educational Recommendations for Improving Drug Prescription in General Practice The Impact of a Pay-for-Performance Scheme on Prescription Quality in Rural China: An Impact Evaluation Prescriber preferences for behavioural economics interventions to improve treatment of acute respiratory infections: a discrete choice experiment Assessing the Effect of Taiwan’s Outpatient Prescription Drug Copayment Policy in the Elderly Impact of a tailored program on the implementation of evidence-based recommendations for multimorbid patients with polypharmacy in primary care practices—results of a cluster-randomized controlled trial Clinical and economic consequences of a reimbursement restriction of nebulised respiratory therapy in adults: direct comparison of randomised and observational evaluations The impact of financial incentives and a patient registry on preventive care quality: increasing provider adherence to evidence-based smoking cessation practice guidelines. An economic analysis of a randomized, controlled, multicenter study of clinical pharmacist interventions for high-risk veterans: the IMPROVE study. Impact of Managed Pharmaceutical Care Resource Utilization and Outcomes in Veterans Affairs Medical Centers. Feedback on prescribing rate combined with problem-oriented pharmacotherapy education as a model to improve prescribing behaviour among general practitioners Repeat prescribing: a role for community pharmacists in controlling and monitoring repeat prescriptions. The effect of education and drug samples on antihistamine prescribing costs in an HMO.
The cost-effectiveness of quality assurance programs is often poorly documented , especially for innovative approaches . The authors analyzed the economic effects of an experimental educational outreach program design ed to reduce inappropriate drug prescribing , based on a four-state r and omized controlled trial ( N = 435 physicians ) . Primary care physicians r and omized into the face-to-face group were offered two individualized educational sessions with clinical pharmacists , lasting an average of 18 minutes each , concerning optimal use of three drug groups that are often used inappropriately . After the program , expenditures for target drugs prescribed by these physicians to Medicaid patients decreased by 13 % , compared with controls ( P = 0.002 ) ; this effect was stable over three quarters . Implementation of this program for 10,000 physicians would lead to projected drug savings ( to Medicaid only ) of $ 2,050,000 , compared with re source costs of $ 940,000 . Net savings remain high , even after adjustment for use of substitution medications . Although there was a ninefold difference in average preintervention prescribing levels between the highest and lowest thirds of the sample , all groups reduced target drug expenditures at the same rate . Targeting of higher-volume prescribers would thus further raise the observed benefit-to-cost ratio from approximately 1.8 to at least 3.0 . Net benefits would also increase further if non-Medicaid savings were added , or if the analysis included quality -of-care considerations . Although print material s alone may be marginally cost-effective , print plus face-to-face approaches offer greater net benefits . The authors conclude that a program of brief , face-to-face “ detailing ” visits conducted by academic rather than commercial sources can be a highly cost-effective method for improving drug therapy decisions . Such an approach makes possible the enhancement of physicians ' clinical expertise without relying on restriction of drug choices 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 r and omly 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 , result ing in substantial cost savings . No such change was seen in physicians who received mailed print material s 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 In analyzing a university-based program to educate physicians about proper medication use , we sought to measure whether physician background characteristics and the quality or number of educational exposures influenced the rate of relinquishment of inappropriate prescribing . A sample of 435 doctors was r and omized to control and experimental groups ; interventions consisted of printed educational material s and face-to-face visits by clinical pharmacists . The program sought to reduce inappropriate use of three drug categories : propoxyphene , peripheral/cerebral vasodilators , and cephalexin . Outcome data included the total volume ( tablets/capsules ) of these drugs prescribed through Medicaid by each study physician 9 months before and after the program . We estimated average changes in prescribing levels by experimental and control physicians within each physician subgroup ( e.g. , board-certified versus uncertified ) , adjusting for prescribing level in the same 9 months of the previous year . The results indicated that the rate of prescribing change was independent of most physician background characteristics studied , including age , board certification , specialty , rural versus urban practice , intensity of previous target drug use , and size of Medicaid practice . Experimental effects were highly significant ( -9 % to -20 % , P < 0.025 ) in 11 of 14 physician subgroups . The presence of a follow-up reinforcement visit was a strong independent predictor of prescribing change ( P < 0.05 ) . An increase from one visit to two visits was associated with an approximate doubling of the size of the program effect . However , total exposure time was not related to changes in prescribing behavior . These findings document that face to face education can be effective in improving the prescribing practice s of a wide variety of physicians , and that brevity , repetition , and reinforcement of recommended practice s are important components in the design of such programs This prospect i ve , r and omized , controlled trial , based in a Veterans Administration Hospital general medicine clinic , compared the cost effectiveness of two behaviorally oriented interventions design ed 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 result ed 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 < 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 result ed 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 CONTEXT Rising costs of medications and inequities in access have sparked calls for drug policy reform in the United States and Canada . Control of drug expenditures by prescription cost-sharing for elderly persons and poor persons is a contentious issue because little is known about the health impact in these subgroups . OBJECTIVES To determine ( 1 ) the impact of introducing prescription drug cost-sharing on use of essential and less essential drugs among elderly persons and welfare recipients and ( 2 ) rates of emergency department ( ED ) visits and serious adverse events associated with reductions in drug use before and after policy implementation . DESIGN AND SETTING Interrupted time-series analysis of data from 32 months before and 17 months after introduction of a prescription coinsurance and deductible cost-sharing policy in Quebec in 1996 . Separate 10-month prepolicy control and postpolicy cohort studies were conducted to estimate the impact of the drug reform on adverse events . PARTICIPANTS A r and om sample of 93 950 elderly persons and 55 333 adult welfare medication recipients . MAIN OUTCOME MEASURES Mean daily number of essential and less essential drugs used per month , ED visits , and serious adverse events ( hospitalization , nursing home admission , and mortality ) before and after policy introduction . RESULTS After cost-sharing was introduced , use of essential drugs decreased by 9.12 % ( 95 % confidence interval [ CI ] , 8.7%-9.6 % ) in elderly persons and by 14.42 % ( 95 % CI , 13.3%-15.6 % ) in welfare recipients ; use of less essential drugs decreased by 15.14 % ( 95 % CI , 14.4%-15.9 % ) and 22.39 % ( 95 % CI , 20.9%-23.9 % ) , respectively . The rate ( per 10 000 person-months ) of serious adverse events associated with reductions in use of essential drugs increased from 5.8 in the prepolicy control cohort to 12.6 in the postpolicy cohort in elderly persons ( a net increase of 6.8 [ 95 % CI , 5.6 - 8.0 ] ) and from 14.7 to 27.6 in welfare recipients ( a net increase of 12.9 [ 95 % CI , 10.2 - 15.5 ] ) . Emergency department visit rates related to reductions in the use of essential drugs also increased by 14.2 ( 95 % CI , 8.5 - 19.9 ) per 10 000 person-months in elderly persons ( prepolicy control cohort , 32.9 ; postpolicy cohort , 47.1 ) and by 54.2 ( 95 % CI , 33.5 - 74.8 ) among welfare recipients ( prepolicy control cohort , 69.6 ; postpolicy cohort , 123.8 ) . These increases were primarily due to an increase in the proportion of recipients who reduced their use of essential drugs . Reductions in the use of less essential drugs were not associated with an increase in risk of adverse events or ED visits . CONCLUSIONS In our study , increased cost-sharing for prescription drugs in elderly persons and welfare recipients was followed by reductions in use of essential drugs and a higher rate of serious adverse events and ED visits associated with these reductions AIMS The aims of this study were to conduct a r and omised controlled trial to evaluate the cost-effectiveness of tailored , postal feedback on general practitioners ' ( GPs ) prescribing of acamprosate and naltrexone for alcohol dependence relative to current practice and its impact on alcohol dependence morbidity . METHODS Rural communities in New South Wales , Australia , were r and omised into experimental ( N=10 ) and control ( N=10 ) communities .  Tailored feedback on their prescribing of alcohol pharmacotherapies was mailed to GPs from the experimental communities ( N=115 ) .  Segmented regression analysis was used to examine within and between group changes in prescribing and alcohol dependence hospitalisation rates compared to the control communities . Incremental cost-effectiveness ratios ( ICERs ) were estimated per additional prescription of pharmacotherapies and per alcohol dependence hospitalisation(s ) averted . RESULTS Post-intervention changes , relative to the control communities , in GPs ' prescribing rate trends in the experimental communities significantly increased for acamprosate ( β=0.24 , 95 % CI : 0.13 - 0.35 , p<0.001 ) , and significantly decreased for naltrexone ( β = -0.12 , 95 % CI : -0.17 to -0.06 ) per quarter . Quarterly hospitalisation trend rates for alcohol dependence , as principal diagnosis , significantly decreased ( β=-0.07 , 95 % CI : -0.13 to -0.01 , p<0.05 ) , compared to control communities . The median ICER per quarterly hospitalisation(s ) averted due to intervention was dominant ( dominant--$12,750 ) . CONCLUSION Postal , tailored feedback to GPs on their prescribing of acamprosate and naltrexone for alcohol dependence was a cost-effective intervention , in rural communities of NSW , to increase the overall prescribing of pharmacotherapies with a plausible effect on incidence reduction of hospitalisations for alcohol dependence as principal diagnosis Background : Although there is a great concern regarding rational use of drugs , the available evidence for the most appropriate strategies to improve prescribing is scarce . Goal : The goal of this study was to evaluate the effectiveness of the combination of feedback of individualized prescribing data and educational recommendations for improving the quality of prescribing in general practice . Method : A quasiexperimental intervention study was conducted in which prescribing rates of 282 family physicians before and after the intervention were compared . Physicians assigned to the individualized feedback group ( n = 195 ) received individual instruction with specific recommendations for improvement according to their baseline prescribing quality levels , whereas physicians in the minimal intervention group ( n = 87 ) only received st and ard nonindividualized prescribing data for the practice group as a whole . Results : A trend toward increasing high pharmacologic intrinsic value in both groups was observed . Overprescription of antibiotics showed a decrease in the individualized feedback group ( P = 0.006 ) and it did not change in the minimal intervention group . A different trend in the values in each group was observed with nonsteroidal antiinflammatory drugs , although it was not statistically significant . Overprescription of antiulcerative agents decreased among physicians in the individualized feedback group ( P = 0.003 ) ; however , there were not statistically significant differences as compared with the minimal intervention group . Changes in indicators of drug selection were more favorable for the group with individualized feedback , although no statistically significant differences were observed . Pharmaceutical expenditure increased significantly in the minimal intervention group as compared with the individualized feedback group , with an approximate difference of $ 7.87 per inhabitant and trimester ( P = 0.003 ) . Conclusion : The intervention showed that improving the quality of prescribing was feasible , particularly in overprescribing , and was associated with considerable savings in pharmaceutical costs In China , health care providers have traditionally been paid fee-for-service and overprescribing and high out-of-pocket spending are common . In this study , township health centers in two counties were assigned almost r and omly to two groups : in one , fee-for-service was replaced by a global capitated budget ; in the other , by a mix of global capitated budget and pay-for-performance . Performance captured inter alia " irrational " drug prescribing ; 20 percent of the global capitated budget was withheld each quarter , points were deducted for failure to meet targets , and some of the withheld budget was returned in line with the points deducted . Outcomes included appropriate prescribing and prescription cost , data on which were obtained by digitizing prescriptions from a month just before the reform and from the same month a year later . Impacts were assessed via multivariate differences-in-differences with township health center fixed effects . To reduce bias from non-r and omness in assignment , the sample was trimmed by coarsened exact matching . Pay-for-performance reduced inappropriate prescribing significantly and substantially in the county where the initial level was above the penalty threshold , but end-line rates were still appreciable ; no effects were seen in the county where initial levels were around or below the threshold , or on out-of-pocket spending in either county Objective To elicit prescribers ' preferences for behavioural economics interventions design ed to reduce inappropriate antibiotic prescribing , and compare these to actual behaviour . Design Discrete choice experiment ( DCE ) . Setting 47 primary care centres in Boston and Los Angeles . Participants 234 primary care providers , with an average 20 years of practice . Main outcomes and measures Results of a behavioural economic intervention trial were compared to prescribers ' stated preferences for the same interventions relative to monetary and time rewards for improved prescribing outcomes . In the r and omised controlled trial ( RCT ) component , the 3 computerised prescription order entry-triggered interventions studied included : Suggested Alternatives ( SA ) , an alert that populated non-antibiotic treatment options if an inappropriate antibiotic was prescribed ; Accountable Justifications ( JA ) , which prompted the prescriber to enter a justification for an inappropriately prescribed antibiotic that would then be documented in the patient 's chart ; and Peer Comparison ( PC ) , an email periodically sent to each prescriber comparing his/her antibiotic prescribing rate with those who had the lowest rates of inappropriate antibiotic prescribing . A DCE study component was administered to determine whether prescribers felt  SA , JA , PC , pay-for-performance or additional clinic time  would most effectively reduce their inappropriate antibiotic prescribing . Willingness-to-pay ( WTP ) was calculated for each intervention . Results In the RCT , PC and JA were found to be the most effective interventions to reduce inappropriate antibiotic prescribing , whereas SA was not significantly different from controls . In the DCE however , regardless of treatment intervention received during the RCT , prescribers overwhelmingly preferred SA , followed by PC , then JA . WTP estimates indicated that each intervention would be significantly cheaper to implement than pay-for-performance incentives of $ 200/month . Conclusions Prescribing behaviour and stated preferences are not concordant , suggesting that relying on stated preferences alone to inform intervention design may eliminate effective interventions . Trial registration number NCT01454947 ; Results Objectives . This study uses variance cost analysis and regression analysis as tools for investigating the initial effects of Taiwan ’s outpatient prescription drug copayment program in the elderly . Under its new National Health Insurance program , Taiwan implemented a  prescription drug cost-sharing program  August 1 , 1999 . We compare an elderly population ’s prescription drug use after the policy  was implemented with an elderly population ’s prescription drug use before the policy change to describe initial and general consequences of the drug cost-sharing program . Methods . Approximately 240,000 patients aged 65 and over representing 1,600,000 outpatient prescriptions were drawn from 21 hospitals in the Taipei area for the study using a stratified r and om sampling method . Variance analysis , as used primarily in accounting , was applied to decompose overall cost variance of the policy into the sum of variances of several specific factors that are important to policymakers . The cost variances of each specific factor can be further decomposed into sublevels of analyses . Regression analysis is then applied to better underst and covariates that might influence drug cost variances of significant magnitude . Results . The initial effects of the policy change did not reverse the trend of drug cost increases . Instead , there was a significant increase in total prescription drug costs in the cost-sharing group ( approximately 12.86 % ) and an even higher increase rate in the non-cost-sharing group ( approximately 51.42 % ) . The main reason for the drug cost increase for the cost-sharing group was attributed to an increase in average drug costs per prescription ( explaining 69.20 % of the variance ) . We found physicians seemed to prescribe more expensive drugs and extend prescription duration , especially when drug costs exceed the upper bound of the cost-sharing schedule . By contrast , the main factor contributing to the increase in drug costs for the non-cost-sharing group was an increase in average prescription duration ( explaining 64.98 % of the variance ) . The increase mainly results from the effect of extended prescriptions for chronic diseases that were design ed to reduce unnecessary visits for refills . Discussion . The significant increase in average drug price per prescription indicates that many prescriptions could move above the upper bound of the cost-sharing schedule . The results suggest that the Bureau of National Health Insurance should increase the upper bound . We do not think these effects are unique to Taiwan . Rather , these effects should be considered as countries change their outpatient drug benefit programs . We also found a decrease in utilization of essential drugs with an increase in utilization of nonessential drugs for patients subject to copayments . The results suggest potential adverse effects on patients ’ health outcome Background Multimorbid patients receiving polypharmacy represent a growing population at high risk for negative health outcomes . Tailoring is an approach of systematic intervention development taking account of previously identified determinants of practice . The aim of this study was to assess the effect of a tailored program to improve the implementation of three important processes of care for this patient group : ( a ) structured medication counseling including brown bag review s , ( b ) the use of medication lists , and ( c ) structured medication review s to reduce potentially inappropriate medication . Methods We conducted a cluster-r and omized controlled trial with a follow-up time of 9 months . Participants were general practitioners ( GPs ) organized in quality circles and participating in a GP-centered care contract of a German health insurance . Patients aged > 50 years , suffering from at least 3 chronic diseases , receiving more than 4 drugs , and being at high risk for medication-related events according to the assessment of the treating GP were enrolled . The tailored program consisted of a workshop for GPs and health care assistants , educational material s and reminders for patients , and the elaboration of implementation action plans . The primary outcome was the change in the degree of implementation between baseline and follow-up , measured by a summary score of 10 indicators . The indicators were based on structured surveys with patients and GPs . Results We analyzed the data of 21 GPs ( 10 - intervention group , 11 - control group ) and 273 patients ( 130 - intervention group , 143 - control group ) . The increase in the degree of implementation was 4.2 percentage points ( 95 % confidence interval : −0.3 , 8.6 ) higher in the intervention group compared to the control group ( p = 0.1 ) . Two of the 10 indicators were significantly improved in the intervention group : medication counseling ( p = 0.017 ) and brown bag review ( p = 0.012 ) . Secondary outcomes showed an effect on patients ’ self-reported use of medication lists when buying drugs in the pharmacy ( p = 0.03 ) . Conclusions The tailored program may improve implementation of medication counseling and brown bag review whereas the use of medication lists and medication review s did not improve . No effect of the tailored program on the combined primary outcome could be substantiated . Due to limitations of the study , results have to be interpreted carefully . The factors facilitating and hindering successful implementation will be examined in a comprehensive process evaluation . Trial registration numberIS RCT N34664024 , assigned Abstract Objective To compare the results of a r and omised and an observational evaluation of the same policy that restricted reimbursement for nebulised respiratory medications in adult patients in a community setting . Design s Cluster r and omised controlled trial and observational time series with historical controls . Setting Pharmacare , the government funded drug benefits plan for elderly people and patients receiving social assistance in British Columbia , Canada . Participants In the r and omised controlled trial 104 clusters of medical practice s , pair matched by geography and approximately by practice size , were r and omised to the intervention group ( 449 patients affected by the policy on 1 March 1999 ) , and the control group ( offered a six month exemption , affecting 386 patients ) . The observational analysis included all Pharmacare beneficiaries ( excluding the 386 exempt patients ) who had used any nebulised drugs six months before the policy ( 4624 patients ) . Intervention Pharmacare restricted reimbursement for nebulised bronchodilators , steroids , and cromoglycate to patients whose doctors applied for an individual patient 's exemption , giving an appropriate clinical reason . Main outcome measures Number of contacts with doctors and services , emergency admissions to hospital , and utilisation of and expenditure for respiratory drugs in data bases of British Columbia 's Ministry of Health . Results Contacts with doctors or emergency admissions to hospital did not increase in association with the restriction , regardless of the analytical approach . In the observational analysis , we found a reduction of $ C24 per patient month in all nebulised drug use ( 95 % confidence interval 19 to 29 ) and an increase of $ C3 per patient month in all expenditure for inhalers ( 1.4 to 4.5 ) . The r and omised evaluation found savings of $ C8 per patient month for nebulisers ( P = 0.24 ) and no increase in spending on inhalers ( P = 0.79 ) . Correcting for 60 % non-compliance by exempt doctors in a sensitivity analysis yielded similar results as the observational evaluation . Conclusions Observational as well as r and omised analyses found moderate net savings and no increase in unintended healthcare outcomes after restricting reimbursement for nebulised respiratory drugs . R and omised policy trials are feasible and , if carefully implemented , likely to be concordant with observational evaluations BACKGROUND This study tested the effects of two organizational support processes , the provision of financial incentives for superior clinical performance and the availability of a  patient ( smoker ) registry and proactive telephone support system for smoking cessation , on provider adherence to accepted practice guidelines and associated patient outcomes . METHODS Forty clinics of a large multispecialty medical group practice providing primary care services were r and omly allocated to study conditions . Fifteen clinics each were assigned to the experimental conditions " control " ( distribution of printed versions of smoking cessation guidelines ) and " incentive " ( financial incentive pay-out for reaching preset clinical performance targets ) .  Ten clinics were r and omized to receive financial incentives combined with access to a central ized patient registry and intervention system ( " registry " ) . Main outcome measures were adherence to smoking cessation clinical practice guidelines and patients ' smoking cessation behaviors . RESULTS  Patients ' tobacco use status  was statistically significant ( P < 0.01 ) more frequently identified in clinics with the opportunity for incentives and access to a registry than in clinics in the control condition . Patients visiting registry clinics accessed counseling programs statistically significantly more often ( P < 0.001 ) than patients receiving care in the control condition . Other endpoints did not statistically significantly differ between the experimental conditions . CONCLUSIONS The impact of financial incentives and a patient registry/intervention system in improving smoking cessation clinical practice s and patient behaviors was mixed . Additional research is needed to identify conditions under which such organizational support processes result in significant health care quality improvement and warrant the investment STUDY OBJECTIVE To determine if clinical pharmacists could affect economic re source use and humanistic outcomes in an ambulatory , high-risk population . DESIGN Prospect i ve , r and omized , controlled study . SETTING Nine Veterans Affairs medical centers . PATIENTS Patients who were at high risk for medication-related problems . INTERVENTION Patients were r and omized to usual medical care with input from a clinical pharmacist ( intervention group ) or just usual medical care ( control group ) . MEASUREMENTS AND MAIN RESULTS Of 1,054 patients enrolled , 523 were r and omized to the intervention group and 531 to the control group . The number of clinic visits increased in the intervention group ( p=0.003 ) , but there was no difference in clinic costs . Mean increases in total health care costs were $ 1,020 for the intervention group and $ 1,313 for the control group ( p=0.06 ) . CONCLUSION Including the cost of pharmacist interventions , overall health care expenditures were similar for patients r and omized to see a clinical pharmacist versus usual medical care Abstract Objective : To develop a working model with which prescribing behaviour among general practitioners might be influenced . Design : Intervention based on feedback on prescribing rates and problem-oriented educational outreach visits , using educational material and local opinion leaders . R and omised study with three parallel intervention groups of general practitioners , which also served as controls for each other . The pharmacotherapeutic fields chosen were hypertension , peptic ulcer/dyspepsia and depression . Prescription data were retrieved from the electronic patient records for periods of 1 year before and after the intervention . Setting : Six health care centres and three continuing medical education groups in Stockholm . Subjects : Forty general practitioners . Main outcome measures : Drug prescribing rates and patterns before and after the intervention . Results : In the hypertension field , desired trends in fractional prescribing ( favouring diuretics and beta blocking agents ) were recorded , with a significant ( P<0.05 ) effect on prescriptions for agents acting on the renin – angiotensin system , despite a pre-existing prescribing behaviour already much in line with the goals . In the peptic ulcer/dyspepsia field , desired trends were recorded for both types of therapies addressed . The fractional prescribing rates for proton-pump inhibitors decreased from 61.0 % to 52.6 % in the intervention arm and increased from 68.1 % to 76.0 % in the control arm ( not significant due to low power ) . The depression group focused on better general attention to the disease and only minor changes were registered . Conclusion : Feedback of individual prescribing rates , combined with problem-oriented educational outreach visits , is a promising model for the improvement of prescribing behaviour . Data from the electronic patient record were feasible for feedback on prescribing rates BACKGROUND Traditional systems of managing repeat prescribing have been criticised for their lack of clinical and administrative controls . AIM To compare a community pharmacist-managed repeat prescribing system with established methods of managing repeat prescribing . METHOD A r and omised controlled intervention study ( 19 general medical practice s , 3074 patients , 62 community pharmacists ) . Patients on repeat medication  were given sufficient three-monthly scripts , endorsed for monthly dispensing , to last until their next clinical review consultation with their general practitioner ( GP ) . The scripts were stored by a pharmacist of the patient 's choice . Each monthly dispensing was authorised by the pharmacist , using a st and ard protocol . The cost of the drugs prescribed and dispensed was calculated . Data on patient outcomes were obtained from pharmacist-generated patient records and GP notes . RESULTS A total of 12.4 % of patients had compliance problems , side-effects , adverse drug reactions , or drug interactions identified by the pharmacist . There were significantly more problems identified in total in the intervention group . The total number of consultations , deaths , and non-elective hospital admissions was the same in both groups . Sixty-six per cent of the study patients did not require their full quota of prescribed drugs , representing 18 % of the total prescribed costs ( estimated annual drug cost avoidance of 43 Pounds per patient ) . CONCLUSION This system of managing repeat prescribing has been demonstrated to be logistically feasible , to identify clinical problems , and to make savings in the drugs bill OBJECTIVE To examine the effect of an intervention design ed to reduce antihistamine prescribing costs in an HMO . DESIGN A quasi-experimental design with clinicians at one HMO site receiving an intervention . Their prescribing behavior before and after the intervention was compared to the prescribing behavior of clinicians at other HMO sites in a non-r and omized control group . SETTING A mixed model HMO in metropolitan Washington , DC . PARTICIPANTS Group model clinicians at a single site received the intervention ; network and group model clinicians at other sites composed the  control  group . INTERVENTION An education memo addressed to clinicians discussing antihistamine prescribing costs and strategies for initial use of nonprescription or less expensive prescription agents , coupled with free antihistamine sample " trial packs " for patient use . OUTCOME MEASURE The prescribing costs of the intervention group were compared to the prescribing costs of the non-r and omized control group . The intervention group was surveyed regarding their attitudes toward the intervention . RESULTS A 2 % decline in costs was noted between the baseline and intervention year for both the intervention and control groups . Though clinicians indicated they were well disposed toward the intervention , they believe patient expectations were a major obstacle to the use of cheaper agents . CONCLUSION We conclude that an effective intervention would require the targeting of major patient-related barriers to clinician behavior change
Although financial incentives are considered an important element in strategies to change prescribing patterns , limited evidence of their effects can be found .
BACKGROUND The proportion of total healthcare expenditures spent on drugs has continued to grow in countries of all income categories .
Policy-makers are under pressure to control pharmaceutical expenditures without adversely affecting quality of care .
Financial incentives seeking to influence prescribers ' behaviour include budgetary arrangements at primary care and hospital setting s ( pharmaceutical budget caps or targets ) , financial rewards for target behaviours or outcomes ( pay for performance interventions ) and reduced benefit margin for prescribers based on medicine sales and prescriptions ( pharmaceutical reimbursement rate reduction policies ) .
This is the first up date of the original version of this review .
OBJECTIVES To determine the effects of pharmaceutical policies using financial incentives to influence prescribers ' practice s on drug use , healthcare utilisation , health outcomes and costs ( expenditures ) .