Effectiveness of medicines review with web-based pharmaceutical treatment algorithms in reducing potentially inappropriate prescribing in older people in primary care: a cluster randomized trial (OPTI-SCRIPT study protocol) Implementing Antibiotic Practice Guidelines through Computer-Assisted Decision Support: Clinical and Financial Outcomes Influence of Simple Computerized Feedback on Prescription Charges in an Ambulatory Clinic: A Randomized Clinical Trial The effects of expanded mental health benefits on treatment costs. Pharmacist-led medication review in patients over 65: a randomized, controlled trial in primary care. Tapering off benzodiazepines in long-term users: an economic evaluation. The value of inpatient pharmaceutical counselling to elderly patients prior to discharge. The Influence of “Stock out” on Health-Seeking Behavior of Low Income Women in Uyo Urban, Akwa Ibom State, Nigeria Safer Prescribing--A Trial of Education, Informatics, and Financial Incentives. Evaluation of a hospital-based community liaison pharmacy service in Northern Ireland Effect of Educational Interventions and Medical School Policies on Medical Students' Attitudes Toward Pharmaceutical Marketing Practices: A Multi-Institutional Study Economic and Policy Analysis of University-based Drug “Detailing
Background Potentially inappropriate prescribing in older people is common in primary care and can result in increased morbidity , adverse drug events , hospitalizations and mortality . In Irel and , 36 % of those aged 70 years or over received at least one potentially inappropriate medication , with an associated expenditure of over € 45 million . The main objective of this study is to determine the effectiveness and acceptability of a complex , multifaceted intervention in reducing the level of potentially inappropriate prescribing in primary care . Methods / design This study is a pragmatic cluster r and omized controlled trial , conducted in primary care ( OPTI-SCRIPT trial ) , involving 22 practice s ( clusters ) and 220 patients . Practice s will be allocated to intervention or control arms using minimization , with intervention participants receiving a complex multifaceted intervention incorporating academic detailing , medicines review with web-based pharmaceutical treatment algorithms that provide recommended alternative treatment options , and tailored patient information leaflets . Control practice s will deliver usual care and receive simple patient-level feedback on potentially inappropriate prescribing . Routinely collected national prescribing data will also be analyzed for nonparticipating practice s , acting as a contemporary national control . The primary outcomes are the proportion of participant patients with potentially inappropriate prescribing and the mean number of potentially inappropriate prescriptions per patient . In addition , economic and qualitative evaluations will be conducted . Discussion This study will establish the effectiveness of a multifaceted intervention in reducing potentially inappropriate prescribing in older people in Irish primary care that is generalizable to countries with similar prescribing challenges . Trial registration Current controlled trials IS RCT Physicians ' decisions control between 70 % and 80 % of all health care dollars spent [ 1 - 3 ] , and many strategies to influence or control physician decision making have been advocated . These strategies include education , peer review with feedback , administrative interventions , financial incentives and penalties , critical pathways , and , most recently , nationally derived guidelines [ 2 , 4 ] . To date , none of these strategies has been clearly effective [ 4 ] . Berwick [ 5 ] has outlined the inherent flaws in many of these strategies . He concedes that these methods may lead to predictable care but notes that they can not lead to continual improvement of care . Nowhere in health care are these strategies to control or influence physicians more prevalent than in the area of drug use , particularly use of antimicrobial agents [ 6 ] . The hospital-wide use of drugs and the involvement of various health care providers create a system of diffuse responsibility , enormous variation , and escalating costs [ 6 - 9 ] . The United States currently spends $ 40 billion annually on pharmaceuticals ; this is 8 % of the total cost of health care [ 3 , 7 - 9 ] . Prescription drugs now constitute between 5 % and 20 % of an individual hospital 's total budget [ 7 ] . Antimicrobial agents are one of the costliest categories of drug expenditures in hospitals , accounting for approximately 20 % to 50 % of total spending on drugs [ 9 - 14 ] . Investigations in various clinical practice setting s have indicated that as much as 50 % of antibiotic use is inappropriate [ 14 - 17 ] . The consequences of this have been addressed in terms of antimicrobial resistance [ 18 , 19 ] , adverse drug reactions [ 15 , 17 ] , and cost [ 11 - 14 ] . In response to these pressures , professional societies and individual investigators have outlined methods with which to improve antibiotic use [ 20 - 29 ] . Most of these methods ( for example , drug formularies ) use some form of a control mechanism , and , to date , experience with them has been mixed [ 11 , 16 , 25 , 27 , 28 ] . Kassirer [ 30 ] has challenged the health care system to develop strategies that inform rather than enforce or control medical decisions . For more than a decade , we have been developing and investigating clinical management programs that augment and inform clinical decision making , in addition to focusing on continual quality improvement [ 31 , 32 ] , in antibiotic therapy , infection control surveillance , and the safety of drug use . These programs were design ed to provide continuous surveillance and computer-assisted decision support [ 33 , 34 ] to all clinicians responsible for inpatient care in a general hospital . The hallmark of these computer-assisted decision support programs was local clinician-derived consensus practice guidelines [ 5 , 31 , 34 , 35 ] that were programmed into a hospital information system as rules , algorithms , and predictive models . These programs managed antibiotic use at three basic levels : prophylactic use , empiric use , and therapeutic use . We review the clinical and process outcomes and the financial effects of these hospital-wide decision support programs during a 7-year period . Methods LDS Hospital , located in Salt Lake City , Utah , is a 520-bed private , community , acute-care referral hospital that serves as a teaching facility for the University of Utah Schools of Medicine , Nursing , and Pharmacy . The hospital provides most clinical services but not general pediatric care . An integrated , clinical ly oriented hospital information system has been under development at the institution for more than 20 years [ 36 ] . This system routinely collects and stores all patient data from multiple sources throughout the hospital . The system currently serves as the hospital 's clinical computing system , providing clinical information management and establishing computer-based patient records . The computer-based patient record contains both clinical and financial data . The financial data are derived from a st and ard cost-manager microcomputer software system that is linked to the clinical information system [ 37 , 38 ] . The information system also provides online clinical decision support through its expert system capabilities . Infectious diseases surveillance and therapeutics was the first medical domain to use the expert system features of the hospital information system on a widespread clinical basis [ 39 ] . The clinical decision support systems and the implementation methods for this domain were developed , tested , and implemented by clinical investigators in the Division of Infectious Diseases at LDS Hospital [ 37 - 52 ] . The process used to develop the local consensus guidelines for antimicrobial use was similar to the approach described by East and colleagues [ 34 ] . Our approach also included thorough evaluations of published reports , use of national guidelines and local expert opinion , and exhaustive analyses of the LDS Hospital patient data base ; we subsequently developed step-wise logistic regression models [ 48 , 49 ] . Through various committee representations , we also frequently consulted the medical staff of LDS Hospital ; in these consultations , we presented data and interim results . Using the aforementioned formal techniques [ 34 , 35 ] , the staff also helped develop , test , and implement the clinical practice guidelines that were embedded in the decision support programs . The practice guidelines were encoded into the knowledge base of the hospital information system as rules , algorithms , and predictive models . This allowed for decision support at the point of care , with feedback to physicians in real time . Thus , guideline application was patient specific , and recommendations corresponded to actual clinical conditions at a particular point in time . Feedback to physicians was open looped [ 53 ] , and the physicians ultimately decided whether or not to follow the recommendations . Since 1985 , many of these clinical decision support programs and guidelines have been prospect ively developed and tested in the patient population s of LDS Hospital , often in r and omized studies . Decision support programs have been systematic ally exp and ed to include comprehensive , institution-wide antibiotic management programs . These decision support programs were design ed to comprehensively manage all antibiotic agents used in the institution throughout the continuum of hospital care : 1 ) prophylactic [ surgical ] antibiotic use ; 2 ) empiric antibiotic use [ for suspected infection without microbiological data ] ; and 3 ) therapeutic antibiotic use ( for established infection with microbiological data ) . These programs continually track and assist physicians in managing each patient treated with an antibiotic at LDS Hospital and in all aspects of antibiotic use ; no antibiotic can be prescribed at LDS Hospital without being affected by these decision support programs . The methods used in these programs have been described elsewhere [ 37 - 52 ] . These programs are continually up date d as medical knowledge and the health care delivery system change , both locally and nationally . The surgical prophylactic decision support programs were developed with our surgical colleagues and result ed in strategies that ensured appropriate case selection , delivery time , intra-operative dosing , and duration of antibiotic use rather than solely concentrating on the specific antibiotic agent or class of agents for each surgical procedure [ 41 , 42 , 45 ] . The empiric and therapeutic antibiotic decision support programs provide information to the clinician in the form of computer-generated alerts or suggestions on the following : the presence of resistant pathogens ; untreated infections ; an incorrect dose , route , or interval of an antibiotic ; the absence of current renal function data ; the need for serum drug levels ; population -based probabilities of infections in relation to specific patient variables ; and cost-effective alternatives ( for example , oral therapy or narrower-spectrum agents ) [ 43 , 48 , 49 ] . Furthermore , these management programs monitor patients for excessive or suboptimal antibiotic doses , depending on the patients ' current renal function status [ 46 , 47 ] , and they address the prevention , early detection , and archiving of adverse drug events associated with these agents [ 44 , 46 , 50 ] . All but one of the computer-assisted antibiotic decision support programs described were in clinical use throughout the study period ; the exception was the adverse drug event program , which has been used since 1989 . Beginning in 1985 , investigators in the infectious disease division developed data base analysis programs that quantify antibiotic use and expenditures , identify prescriber and diagnosis-related groups for patients receiving antibiotics , track antibiotic resistance patterns , and distinguish therapeutic from prophylactic use of antibiotics . The reports generated by these data base analysis programs summarize antibiotic use by specific agent and place them in the following categories : numbers of patients treated , total milligrams administered , total doses administered , defined daily doses per 100 occupied bed-days [ 12 , 13 , 54 ] , and total amount spent . We used the number of defined daily doses per 100 occupied bed-days because it is a st and ardized technical unit of measurement that estimates drug use . A defined daily dose is based on the average adult maintenance dose ( usually in grams ) for the primary indication of the drug and is adjusted per 100 occupied bed-days . The concept of the defined daily dose per 100 occupied bed-days was established by a joint project of the Nordic Council on Medicines and the World Health Organization Center for Drug Collaboration Statistics [ 12 , 13 , 54 ] . Because the defined daily dose per 100 occupied bed-days is independent of cost ( which eliminates confounding introduced by the buying practice s of group purchasing organizations ) and differences in dose forms , it establishes a st and ardized basis for comparing drug use . The World Health Organization has agreed that the defined daily dose method of analysis can be Pharmaceuticals account for a significant portion of health care costs and are an important target for attempts at cost reductions . While many techniques have been shown effective , most are re source -intensive , have demonstrated fatigue after the intervention is ceased , and have been directed at specific items rather than total charges . The authors design ed a computerized program to feed back prescription charges . The intervention is easy to execute , inexpensive , and can be maintained indefinitely . The intervention was performed in a r and omized , prospect i ve , controlled trial with the medical residents of a large county hospital . The goal was to reduce total prescribing charges and produce a meaningful financial result . The intervention reduced the mean charge for a prescription by 6.7 % ( P < 0.025 ) , but with a long latent period and minimal impact on resident knowledge of drug charges . Significant differences were seen only at the end of the study . The program was viewed positively by the residents . The low cost of the intervention yielded a benefit-to-cost ratio in excess of 50:1 . Because of computerization and ongoing patient and resident r and omization at the study hospital , added costs of this r and omized trial in terms of computer time and research assistance were less than $ 1,000 BACKGROUND Mental health disorders represent one of the most common problems facing adults in the labor force . It is estimated that within a 12-month period nearly 30 % of the US population experiences some diagnosable mental health or addictive disorder . This study examines the impact that corporate benefit policies can have on mental health treatment costs . AIMS To measure the effects of a change in mental health benefit design on treatment expenditures for employees of a large US-based company . METHODS Data came from mental health treatment administrative cl aims and eligibility information provided by the company and a comparable set of cl aims for a r and omly selected control group for the years 1995 - 1998 . We measure the effect of a change in mental health benefits consisting of three major elements : a company-wide effort to destigmatize mental illness ; reduced cost-sharing for mental health treatment ; and the implementation of a provider network that emphasized access to non-physician mental health specialists . We use a two-part regression model within a difference in differences framework to examine outpatient , pharmaceutical , and combined outpatient and pharmaceutical expenditures between the treatment company and the control group . RESULTS We find that the program led to a statistically significant dollar 17 increase in outpatient costs ( excluding pharmaceutical costs ) per employee . Similar to outpatient care we find that the benefit change was associated with a statistically significant increase in pharmaceutical costs of about dollar 15 . DISCUSSION The results reveal that the mental health benefit expansion at the company led to a significant increase in aggregate mental health expenditures among employees . However , the aggregate increase in cost masks a number of interesting underlying trends in mental health utilization . First , conditional upon any mental health treatment , mental health costs were virtually unchanged before and after the benefit change . Conditional on any use , outpatient and pharmaceutical expenditures went in opposite directions , with outpatient expenditures falling and pharmaceutical expenditures increasing . IMPLICATION S FOR HEALTH CARE PROVISION AND USE Private sector initiatives can increase use of mental health care treatment through decreased cost-sharing , improved access to specialty providers , and destigmatization of mental disorders . IMPLICATION S FOR HEALTH CARE POLICY FORMULATION : Given that the vast majority of people in the US get their health insurance through employer-sponsored health insurance , efforts on the part of the private sector to recognize and treat serious chronic illnesses such as mental disorder in a proactive manner should be encouraged . IMPLICATION S FOR FUTURE RESEARCH While the aggregate cost of corporate initiatives to improve access to quality mental health care is frequently examined , it is also important to decompose the aggregate cost changes into effects from a change in the rate of initiation and changes in utilization conditional upon initiation BACKGROUND regular medication review has been recommended for those over 75 and those on multiple drug therapy . Pharmacists are a potential source of assistance in review ing medication . Evidence of the benefits of this process is needed . OBJECTIVE to study the effect of medication review led by a pharmacist on resolution of pharmaceutical care issues , medicine costs , use of health and social services and health-related quality of life . DESIGN r and omized , controlled trial . SETTING general medical practice s in the Grampian region of Scotl and . SUBJECTS patients aged at least 65 years , with at least two chronic disease states who were taking at least four prescribed medicines regularly . METHODS pharmacists review ed the drug therapy of 332 patients , using information obtained from the practice computer , medical records and patient interviews . In 168 patients , a pharmaceutical care plan was then drawn up and implemented . The 164 control patients continued to receive normal care . All outcome measures were assessed at baseline and after 3 months . RESULTS all patients had at least two pharmaceutical care issues at baseline . Half of these were identified from the prescription record , the rest from notes and patient interview . Of all the issues , 21 % were resolved by information found in notes and 8.5 % by patient interview . General practitioners agreed with 96 % of all care issues documented on the care plans in the intervention group . At the time of follow-up , 70 % of the remaining care issues had been resolved in the intervention group , while only 14 % had been resolved in the control group . There were no changes in medicine costs or health-related quality of life in either group . There were small increases in contacts with health-care professionals and slightly fewer hospital admissions among the intervention group than the control group . CONCLUSIONS pharmacist-led medication review has the capacity to identify and resolve pharmaceutical care issues and may have some impact on the use of other health services BACKGROUND Discontinuation of benzodiazepine usage has never been evaluated in economic terms . This study aim ed to compare the relative costs and outcomes of tapering off long-term benzodiazepine use combined with group cognitive behavioural therapy ( TO+CBT ) , tapering off alone ( TOA ) and usual care . METHOD A r and omised controlled trial was conducted , incorporating a cost-effectiveness analysis from a societal as well as a pharmaceutical perspective . The cost of intervention treatment , prescribed drugs , healthcare services , productivity loss , and patients ' costs were measured using drug prescription data and cost diaries . Costs were indexed at 2001 prices . The principal outcome was the proportion of patients able to discontinue benzodiazepine use during the 18-month follow-up . A secondary outcome measure was quality of life ( Health Utility Index Mark III [ HUI-3 ] and the Medical Outcomes Study 36-item Short-Form Health Survey [ SF-36 ] ) . RESULTS A total of 180 patients were r and omised to one of TO+CBT  ( n = 73 ) , TOA ( n = 73 ) or usual care ( n = 34 ) . Intervention treatment costs were an average of 172.99Euro per patient for TO+CBT and 69.50Euro per patient for TOA . Both treatment conditions significantly reduced benzodiazepine costs during follow-up compared with usual care . The incremental cost-effectiveness ratios ( ICERs ) showed that , for each incremental 1 % successful benzodiazepine discontinuation , TO+CBT cost 10.30 - 62.53Euro versus usual care , depending on the study perspective . However , TO+CBT was extendedly dominated or was dominated by TOA . This result ed in ICERs of 0.57Euro , 10.21Euro and 48.92Euro for TOA versus usual care from the limited pharmaceutical , comprehensive pharmaceutical and societal perspective , respectively . CONCLUSIONS TO+CBT and TOA both led to a reduction in benzodiazepine costs . However , it remains uncertain which healthcare utilisation has a causal relationship with long-term benzodiazepine consumption or its treatment . Although the ICERs indicated better cost effectiveness for TOA than for TO+CBT , the differences were relatively small . The addition of group CBT to tapering off had no clinical or economic advantages . Extrapolation of our data showed that the investment in TOA was paid back after 19 months when corrected for treatment gain with usual care AIMS The use of medication and information discharge summaries ( MIDS ) has become a st and ard procedure in many hospitals . We have evaluated if these summaries , together with in-patient pharmaceutical counselling backed up with a simple medicine reminder card , may help with the delivery of seamless pharmaceutical care . METHODS Elderly patients prescribed more than four items discharged to their own home received the st and ard discharge policy including a recently introduced MIDS and medicine reminder card . Each patient 's GP was sent a copy on discharge . Pre-discharge a pharmacist counselled study patients about their medicines and compliance . A research pharmacist visited patients in their home approximately 2 - 3 weeks and at 3 months post-discharge to determine their drug knowledge , compliance , home medicine stocks and any healthcare related events . RESULTS Forty-three study and 40 control patients completed both visits . Their mean ( s.d . ) ages were 80.2 ( 5,7 ) and 81.1 ( 5,8 ) years and they were prescribed 7.1 ( 1.8 ) and 7.1 ( 2.3 ) items , respectively . At visit 1 knowledge ( P < 0.01 ) and compliance ( P < 0.001 ) was better in the study group . At visit 2 compliance had improved in the study group ( P < 0.001 ) . Unplanned visits to the GP and readmission to hospital amongst the study group were 19 and 5 , respectively , which were both significantly less ( P < 0.05 ) than 27 and 13 in the control group . At visit 2 for the study group the 24 unplanned GP visits and three re-admissions were significantly ( P < 0.05 ) less than the respective 32 and 15 in the control group . At visit 1 , two study group patients had altered their own medication compared with 10 control patients . At visit 2 these reduced to 0 and 4 , respectively . CONCLUSIONS In-patient pharmaceutical counselling , linked to a medication and information discharge summary and a medicine reminder card , contributed to better drug knowledge and compliance together with reduced unplanned visits to the doctor and re-admissions . A pharmaceutical domiciliary visit consoli date d the improved healthcare outcomes The “ Health for All Project ” ( HFAP ) policy in Nigeria was complemented by the National Drug Policy to ensure constant availability of high quality drugs and medical consumables at affordable prices to citizens in public hospitals . Apart from strengthening the utilization of health services , the project also sought to improve health care delivery for the poor who could not afford the high cost of drugs in private clinics and pharmaceutical stores . Employing a survey method with stratified and systematic r and om techniques , the study found failed expectations in the promises of HFAP policy among the 1250 low-income women in Uyo urban . In the face of “ stock out ” where most drugs , pharmaceuticals , and medical supplies are consistently not available for dispensing in public hospitals and health centers poor urban women resorted to alternative health care in prayer houses , herbal homes , patent medicine vendors , health workers homes , and traditional birth attendants . The study reported that stock out in government health facilities result ed in health hazards and the relapse of illnesses as a result of non-adherence to treatment regime and exposure to fake , expired , and adulterated drugs . A renewed commitment in health care delivery in Nigeria is called for if poor women are to be really empowered BACKGROUND High-risk prescribing and preventable drug-related complications are common in primary care . We evaluated whether the rates of high-risk prescribing by primary care clinicians and the related clinical outcomes would be reduced by a complex intervention . METHODS In this cluster-r and omized , stepped-wedge trial conducted in Tayside , Scotl and , we r and omly assigned participating primary care practice s to various start date s for a 48-week intervention comprising professional education , informatics to facilitate review , and financial incentives for practice  s to review patients ' charts to assess appropriateness . The primary outcome was patient-level exposure to any of nine measures of high-risk prescribing of nonsteroidal antiinflammatory drugs ( NSAIDs ) or selected antiplatelet agents ( e.g. , NSAID prescription in a patient with chronic kidney disease or coprescription of an NSAID and an oral anticoagulant without gastroprotection ) . Prespecified secondary outcomes included the incidence of related hospital admissions . Analyses were performed according to the intention-to-treat principle , with the use of mixed-effect models to account for clustering in the data . RESULTS A total of 34 practice s underwent r and omization , 33 of which completed the study . Data were analyzed for 33,334 patients at risk at one or more points in the preintervention period and for 33,060 at risk at one or more points in the intervention period .  Targeted high-risk prescribing was significantly reduced , from a rate of 3.7 % ( 1102 of 29,537 patients at risk ) immediately before the intervention to 2.2 % ( 674 of 30,187 ) at the end of the intervention ( adjusted odds ratio , 0.63 ; 95 % confidence interval [ CI ] , 0.57 to 0.68 ; P<0.001 ) . The rate of hospital admissions for gastrointestinal ulcer or bleeding was significantly reduced from the preintervention period to the intervention period ( from 55.7 to 37.0 admissions per 10,000 person-years ; rate ratio , 0.66 ; 95 % CI , 0.51 to 0.86 ; P=0.002 ) , as was the rate of admissions for heart failure ( from 707.7 to 513.5 admissions per 10,000 person-years ; rate ratio , 0.73 ; 95 % CI , 0.56 to 0.95 ; P=0.02 ) , but admissions for acute kidney injury were not ( 101.9 and 86.0 admissions per 10,000 person-years , respectively ; rate ratio , 0.84 ; 95 % CI , 0.68 to 1.09 ; P=0.19 ) . CONCLUSIONS A complex intervention combining professional education , informatics , and financial incentives reduced the rate of high-risk prescribing of antiplatelet medications and NSAIDs and may have improved clinical outcomes . ( Funded by the Scottish Government Chief Scientist Office ; Clinical Trials.gov number , NCT01425502 . ) Objective : To evaluate the impact of a hospital based community liaison pharmacy service on a range of outcomes in patients aged more than 55 years and taking more than 3 prescribed drugs , who had been admitted to the medical unit of a district general hospital in Northern Irel and . Methods : Having recruited 243 patients , a total of 162 patients completed the full protocol ( 81 r and omly assigned to intervention and 81 to control  ; mean age of control patients 75 years ; mean age of intervention patients 73 years ) . The interventions by the community liaison pharmacist included : preparation of an accurate medication record following a full review of current medication use ; medication counselling ; provision of a medicines record sheet informing the patient how to take their drugs ; provision of a pharmaceutical discharge letter detailing changes made to drug therapy ( this was faxed to the patient 's GP and community pharmacist on the day of discharge ) ; provision of a Medicines Helpline . Results : The key findings were as follows : problems were identified in 80 % of the intervention patients ' prescription charts , 49 % of which related to drug omissions from the patients ' domiciliary prescriptions . The GP practice record was the most accurate ( mean error rate 12.6 % ) while the GP referral letter was the least accurate ( mean error rate 47.3 % ) source of medication information . Drugs patients brought to hospital were also an inaccurate source ( mean error rate 44.0 % ) . The intervention group patients , when compared with control patients , had a significant reduction ( P=0.005 ) in drug mismatch between drugs prescribed at discharge and taken at home , and had a greater knowledge of their drug regimen 10–14 days after discharge ( P |Ld 0.001 ) . The vast majority of patients ( 96 % ) felt that the provision of a medicine helpline was a useful service . Conclusions : The study indicated clear benefits from the involvement of a hospital based community liaison pharmacist in achieving seamless pharmaceutical care between the primary and secondary healthcare setting Purpose To determine the effect of educational interventions on medical students ' attitudes toward pharmaceutical industry marketing practice s and whether restrictive medical school policies governing medicine – industry interactions are associated with student support for banning such interactions . Method Prospect i ve cohort study involving the graduating classes of 2009 ( intervention , n = 474 ) and 2010 ( control , n = 459 ) at four U.S. medical schools . Intervention students experienced a former pharmaceutical representative 's presentation , faculty debate , and a Web-based course . Both groups completed baseline and follow-up attitude surveys about pharmaceutical marketing . Results A total of 482 students ( 51.6 % ) completed both surveys . In regression analyses , intervention students were more likely than control students to think that physicians are strongly or moderately influenced by pharmaceutical marketing ( OR , 2.29 ; 95 % CI , 1.46–3.59 ) and believed they would be more likely to prescribe a company 's drug if they accepted that company 's gifts and food ( OR , 1.68 ; 95 % CI , 1.12–2.52 ) . Intervention students were more likely to support banning interactions between pharmaceutical representatives and students ( OR , 4.82 ; 95 % CI , 3.02–7.68 ) and with physicians ( OR , 6.88 ; 95 % CI , 4.04–11.70 ) . Students from schools with more restrictive policies were more likely to support banning interactions between pharmaceutical representatives and students ( OR , 1.99 ; 95 % CI , 1.26–3.16 ) and with physicians ( OR , 3.44 ; 95 % CI , 2.05–5.79 ) . Conclusions Education about pharmaceutical marketing practice s and more restrictive policies governing medicine – industry interactions seem to increase medical students ' skepticism about the appropriateness of such marketing practice s and disapproval of pharmaceutical representatives in the learning environment 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
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 ) .