In the setting of rising medication costs and influential marketing from the pharmaceutical industry, clinicians increasingly need real-time access to evidence-based information to support prescribing decisions. This study demonstrates that computerized decision support can limit the prescribing of heavily marketed medications in a community-based ambulatory care setting.
Prior studies have demonstrated that computerized prescribing alerts prevent medication errors, reduce the prescribing of inappropriate medications in the elderly, guide dosing in patients with renal insufficiency, limit hypnotic and anticholinergics in hospitalized elderly, and promote the use of formulary medications in the inpatient setting.10–16,23
The present study extends this work by demonstrating the effectiveness of computerized alerts to support prescribing decisions surrounding heavily marketed medications in the ambulatory setting. In a system where physicians are frequently unaware of patients’ out-of-pocket medication expenses24,25
and infrequently discuss costs with patients,26
the novel use of computerized alerts to prompt discussions regarding alternative treatment options offers a potential solution to limit unnecessarily expensive treatments.
Overall, the computerized alerts were well received by the clinicians surveyed. The majority reported that the alerts provided useful evidence to support prescribing decisions and relevant patient educational materials. Many clinicians also indicated that the alerts prompted them to spend more time discussing alternative treatments with patients. Following principles of effective decision support,27–29
the alerts were designed to limit disruptions in workflow by allowing the clinician to prescribe the original or alternative medications, quickly access references, and document the level of service and diagnosis codes for the visit. Furthermore, refills for medications were not subject to the alert, preventing clinicians from repeatedly receiving the same alert for the same patient. Selectively implementing streamlined computerized alerts with diverse functionality is essential to maximizing the alerts’ effectiveness and clinician acceptance.28–30
We did not find an additional effect of educational sessions and educational mailings beyond the effect of the alerts alone. The group educational sessions were focused on providing current prescribing information and facilitating discussions around the use of heavily marketed medications and less costly alternatives. While traditional academic detailing has been effective in improving health care quality in several settings, 31–34
its use in combination with computerized alerts has not demonstrated additive benefit in two prior studies.11,12,31
Nevertheless, group educational sessions remain an enticing option to change physician behavior. While we did not detect an additive effect of a single group-based educational session, we are unable to determine if more intensive sessions–for example, multiple sessions over time, or individual (one-on-one) detailing – would have been more effective.
In the setting of escalating medication costs, the use of computerized alerts to support prescribing offers the potential for significant cost savings. In 2007, total sales of Lunesta® exceeded $600 million dollars35
while sales of Ambien CR® surpassed $751 million dollars.36
Substituting generic agents for even a small fraction of prescriptions for heavily marketed hypnotics would translate into considerable savings to the health care system.
This study has several limitations. First, this study evaluated a single class of medications. There are, however, numerous classes of medications with comparably effective generic equivalents that would be potentially amenable to similar interventions. Second, the alerts were not activated for physicians joining HVMA after the initiation of the study. This may have led to an underestimation of the effect of the alerts. Furthermore, encounters for medication refills were not subject to the alert, preventing clinicians from repeatedly receiving the same alert for the same patient, but further dampening the potential effect of the alerts. Third, the group educational sessions were limited to a single meeting and did not include urgent care providers, limiting the potential efficacy of this educational intervention. Fourth, our data collection was limited to one year after the activation of alerts. Although there was no apparent increasing trend in the number of heavily marketed hypnotics prescribed in the intervention groups during the one year intervention period, we are unable to determine if the effects of the alerts will diminish over time. Lastly, the generalizability of computerized prescribing alerts is limited to clinical settings with electronic prescribing linked to the capability of real-time clinical decision-support. Although a minority of practices have these capabilities at present,37
recent studies have shown encouraging trends of increasing adoption of electronic health records in ambulatory settings.38,39
Moreover, American Recovery and Reinvestment Act of 2009 includes more than $19 billion in financial incentives to speed EHR adoption in the coming years.
In summary, we found that computerized decision support is an effective tool to reduce the prescribing of heavily marketed medications in ambulatory care settings. The alerts held the prescribing of heavily marketed hypnotic medications at pre-intervention levels while the control group experienced an increase in the proportion prescribed. The addition of group educational sessions, however, yielded similar results to the alerts alone. In the setting of escalating medication costs, clinicians increasingly need tools to provide current prescribing information and facilitate discussions surrounding alternative treatment options. Computerized alerts offer an adaptable platform to support evidence-based prescribing and limit the external influences of pharmaceutical marketing.