Brufsky J W, Ross-Degnan D, Calabrese D, Gao X, Soumerai S B
Harvard Pilgrim Health Care, Boston, MA, USA.
Med Care. 1998 Mar;36(3):321-32. doi: 10.1097/00005650-199803000-00009.
This study was undertaken to determine whether a program of education, therapeutic reevaluation of eligible patients, and performance feedback could shift prescribing to cimetidine from other histamine-2 receptor antagonists, which commonly are used in the management of ulcers and reflux, and reduce costs without increasing rates of ulcer-related hospital admissions.
This study used an interrupted monthly time series with comparison series in a large mixed-model health maintenance organization. Physicians employed in health centers (staff model) and physicians in independent medical groups contracting to provide health maintenance organization services (group model) participated. The comparative percentage prescribed of specific histamine-2 receptor antagonists (market share), total histamine-2 receptor antagonist prescribing, cost per histamine-2 receptor antagonist prescription, and the rate of hospitalization for gastrointestinal illness were assessed.
In the staff model, therapeutic reevaluation resulted in a sudden increase in market share of the preferred histamine-2 receptor antagonist cimetidine (+53.8%) and a sudden decrease in ranitidine (-44.7%) and famotidine (-4.8%); subsequently, cimetidine market share grew by 1.1% per month. In the group model, therapeutic reevaluation resulted in increased cimetidine market share (+9.7%) and decreased prescribing of other histamine-2 receptor antagonists (ranitidine -11.6%; famotidine -1.2%). Performance feedback did not result in further changes in prescribing in either setting. Use of omeprazole, an expensive alternative, essentially was unchanged by the interventions, as were overall histamine-2 receptor antagonist prescribing and hospital admissions for gastrointestinal illnesses. This intervention, which cost approximately $60,000 to implement, resulted in estimated annual savings in histamine-2 receptor antagonist expenditures of $1.06 million.
Annual savings in histamine-2 receptor antagonist expenditures after this multifaceted intervention were more than implementation costs, with no discernible effects on numbers of hospitalizations. The magnitude of effect and cost savings were much greater in the staff model; organizational factors and economic incentives may have contributed to these differences. More research is needed to determine the generalizability of this approach to other technologies and managed care settings.
开展本研究以确定一项教育计划、对符合条件的患者进行治疗重新评估以及绩效反馈是否能使处方从其他常用于溃疡和反流管理的组胺-2受体拮抗剂转向西咪替丁，并在不增加溃疡相关住院率的情况下降低成本。
本研究在一个大型混合模式健康维护组织中采用了带有对照系列的间断月度时间序列。参与的有健康中心受雇的医生（员工模式）以及签约提供健康维护组织服务的独立医疗集团的医生（集团模式）。评估了特定组胺-2受体拮抗剂的处方比较百分比（市场份额）、组胺-2受体拮抗剂的总处方量、每种组胺-2受体拮抗剂处方的成本以及胃肠道疾病的住院率。
在员工模式中，治疗重新评估导致首选组胺-2受体拮抗剂西咪替丁的市场份额突然增加（+53.），雷尼替丁（-44.7%）和法莫替丁（-4.8%）的市场份额突然下降；随后，西咪替丁的市场份额每月增长1.1%。在集团模式中治疗重新评估导致西咪替丁市场份额增加（+9.7%），其他组胺-2受体拮抗剂的处方量减少（雷尼替丁-11.6%；法莫替丁-1.2%）。绩效反馈在两种情况下均未导致处方的进一步变化。昂贵的替代药物奥美拉唑的使用基本上未因干预措施而改变，组胺-2受体拮抗剂的总体处方量以及胃肠道疾病的住院情况也是如此。这项实施成本约为60,000美元的干预措施使组胺-2受体拮抗剂支出估计每年节省106万美元。
这项多方面干预措施实施后，组胺-2受体拮抗剂支出的年度节省超过了实施成本，且对住院人数没有明显影响。员工模式中的效果大小和成本节省要大得多；组织因素和经济激励措施可能导致了这些差异。需要更多研究来确定这种方法在其他技术和管理式医疗环境中的可推广性。
