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Conservative Prescribing Could Save Lives, Money
A more cautious approach to prescribing drugs would serve patients better, according to a study published in the June 2011 issue of the Archives of Internal Medicine, which found that shifting to a more conservative model could save lives and money.
Researchers urged physicians to shift away from the mindset that leads them to heavily prescribe the “latest and greatest” new drugs to one that focuses on “fewer and more time-tested” medications. Medical and pharmacy schools should not just teach the pharmacology of drugs, but also principles that would make practitioners better and more cautious prescribers and users of drugs, they wrote.
The principles of conservative prescribing recommended in this “Less is More” series are:
• Think beyond drugs. Consider nondrug therapies such as diet, exercise, or physical therapy; look for and treat underlying causes rather than mask symptoms with drugs; emphasize prevention rather than treatment.
• Practice strategic prescribing. Defer drug treatment if drugs can be safely started after a trial of nondrug therapy. Avoid frequent drug switching; be circumspect about unproven drug uses; start treatment with only 1 new drug at a time.
• Watch for adverse effects. Suspect drug reactions when patients report problems; be aware of withdrawal syndromes; educate patients about side effects so they can anticipate and report reactions.
• Exercise caution regarding new drugs. Seek out unbiased information sources; wait until drugs have proved safe on the market; be skeptical of markers such as improved laboratory-test values rather than true clinical benefits; avoid stretching to include patients or diseases different from those in the clinical trials; avoid seduction by molecular studies that have no proven outcome benefits; beware of reporting that highlights positive trials and hides those that fail to show benefit.
• Work with patients for a shared agenda. Do not automatically yield to patient requests for drugs; consider nonadherence before adding drugs; avoid restarting previously unsuccessful treatments; discontinue any medications that are not needed or not working; and respect patients’ own reservations about drugs.
• Consider long-term, broader impacts. Weigh short-term benefits against long-term outcomes and ecologic impacts. Recognize that improved prescribing and better monitoring may outweigh marginal benefits of new drugs.
“None of these principles are particularly novel, nor should they be terribly controversial,” said study coauthor Bruce Lambert, PhD, of the University of Illinois. “But taken together they represent a radical shift in the way clinicians think about and prescribe drugs.”
Medicaid Drug Lists Cost More, Deliver Less
By ignoring international evidencebased lists of safe and effective medications, the US Medicaid program may be paying far more than necessary for medications and not offering patients the most effective ones available, according to research published in the June 2011 issue of the American Journal of Public Health.
The study, which compared the Medicaid program’s Preferred Drug Lists in 40 states nationwide against the World Health Organization’s (WHO’s) 2009 Essential Medicines List, found that the medications that are automatically paid for by state-run Medicaid programs vary widely from state to state, with few consistent protocols or rationales for their selection, including cost, safety, or effectiveness of the medication.
In 2007, a survey found that 131 of 151 countries use the WHO essential medicines concept—which is designed to help allocate limited resources to the most-needed, safest, and most effective medications—as a basis for their national formulary. The United States, however, was not one of those countries.
“The United States has 51 different lists of medications that are paid for by Medicaid, and only a third of those medications consistently appear on the various lists,” said Lisa A. Bero, PhD, a professor in the University of California at San Francisco School of Pharmacy. “This research suggests that Medicaid could save significant money and also provide safer and more effective medications for patients by using a more consistent approach to deciding which drugs will be covered.”
In the study, researchers identified 369 medicines in the 9 therapeutic classes that had the highest annual Medicaid reimbursements and also were addressed by the WHO list. All but 6 of the 120 WHO medications in those categories also appeared on most of the states’ lists, but their use was inconsistent across the lists. The study found that an additional 249 medicines only appeared on state lists and were not considered as the most effective and safest medications by the WHO.
“The issue is not that our patients cannot get the WHO-recommended medications, but that they are receiving a wide variety of other medications that cost more and are not always as effective or safe,” Dr. Bero said. “This study suggests that if states used the World Health Organization Essential Medicines List as a starting point, patients could have more confidence that the medicines they receive are effective and safe.” PT
iPAD EXTRA: Research estimates that increasing generic prescribing by just 2% would save Medicaid more than $1.3 billion. To learn more about the nation’s rising prescription drug costs, download our free iPad app and go to Pharmacy Insights.