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March 27, 1996

Cost Savings Using a Stepped-Care Prescribing Protocol for Nonsteroidal Anti-inflammatory Drugs

Author Affiliations

From the Internal Medicine Service, Walter Reed Army Medical Center, Washington, DC (Dr Jones); Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, Md (Drs Kroenke and Landry); and Department of Pharmacy, Madigan Army Medical Center, Tacoma, Wash (Dr Tomich and Mr Ferrel).

JAMA. 1996;275(12):926-930. doi:10.1001/jama.1996.03530360036035

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.(JAMA. 1996;275:926-930)