COST SAVINGS USING A STEPPED-CARE PRESCRIBING PROTOCOL FOR NONSTEROIDAL ANTIINFLAMMATORY DRUGS

Objective.-To lower nonsteroidal anti-inflammatory drug (NSAID) costs while maintaining quality patient care and clinician satisfaction. Des ign.-Before and after 21-month trial with one study site and two contr ol 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 requiri ng a trial of either ibuprofen or indomethacin before new prescription of more expensive NSAIDs. One control center used an NSAID computer c ost-prompt and the other had no intervention. Main Outcome Measures.-T he proportion of expensive NSAIDs prescribed at each institution and t otal NSAID costs adjusted for prescription volume. Clinician acceptanc e and patient impact were assessed by the questionnaire. Results.-Stud y site clinicians (n=158) reported very few protocol-related patient c are 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 2 1%, decreasing costs by 30% (P<.001). In contrast, the site with a com puter cost-prompt had only a 5% decrease in NSAID costs, while costs a t the site with no intervention increased 2%. Conclusions.-For drugs w ith similar benefits and adverse effects, a ''stepped formulary'' appr oach requiring an initial trial of one of the less expensive agents ca n maintain physician prescribing choices and satisfaction while loweri ng costs.