Cost savings using a stepped-care prescribing protocol for nonsteroidal anti-inflammatory drugs
D. L. Jones, K. Kroenke, F. J. Landry, D. J. Tomich and R. J. Ferrel
Internal Medicine Service, Walter Reed Army Medical Center, Washington, DC 20307-5001, USA.
OBJECTIVE: To lower nonsteroidal anti-inflammatory drug (NSAID) costs while
maintaining quality patient care and clinician satisfaction. DESIGN: Before
and after 21-month trial with one study site and two control sites and a
questionnaire that was sent to 203 clinicians. SETTING AND SUBJECTS: Two
military medical centers and two affiliated primary care clinics. All
beneficiaries filling outpatient NSAID prescriptions. INTERVENTIONS: An
NSAID prescribing protocol was implemented requiring a trial of either
ibuprofen or indomethacin before new prescription of more expensive NSAIDs.
One control center used an NSAID computer cost-prompt and the other had no
intervention. MAIN OUTCOME MEASURES: The proportion of expensive NSAIDs
prescribed at each institution and total NSAID costs adjusted for
prescription volume. Clinician acceptance and patient impact were assessed
by the questionnaire. RESULTS: Study site clinicians (n=158) reported very
few protocol-related patient care problems. A minority (9%) of study site
clinicians considered the protocol very bothersome, and only 2% felt it
should be discontinued. Quarterly use of expensive NSAIDs at the study site
fell from 34% to 21%, decreasing costs by 30% (P<.001). In contrast, the
site with a computer cost-prompt had only a 5% decrease in NSAID costs,
while costs at the site with no intervention increased 2%. CONCLUSIONS: For
drugs with similar benefits and adverse effects, a "stepped formulary"
approach requiring an initial trial of one of the less expensive agents can
maintain physician prescribing choices and satisfaction while lowering
costs.
