Cost savings using a stepped-care prescribing protocol for nonsteroidal anti-inflammatory drugs.

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.