Therapeutic substitution and therapeutic conservatism as cost-containment strategies in primary care: a study of fundholders and non-fundholders

Background. General practice (GP) fundholders contained prescribing costs b y restricting the rise in volume of prescribing and by increasing generic p rescribing. It is uncertain whether they used more sophisticated approaches to medicine choice in attempts to contain costs. Aim. To examine whether fundholding practices have adopted medicine-specifi c strategies to contain prescribing costs - i.e. switching to less expensiv e but equally effective medicines or resisting the uptake of newer more exp ensive medicines - by examination of the prescribing of ulcer-healing and a ntidepressant medicines in the period before and after practices became fun dholders. Method. Comparison of prescribing data of 52 fundholding practices before f undholding and after fundholding with that of matched non-fundholding pract ices. Measures examined were prescribing costs (net ingredient cost in each therapeutic area per ASTRO-pu); prescribing volume (defined daily doses pe r ASTRO-pu); the proportion of all ulcer-healing medicines prescribed as ci metidine, ranitidine, nizatidine, and as proton pump inhibitors; and the pr oportion of all antidepressant medicines prescribed as selective serotonin re-uptake inhibitors. Results. In comparison with non-fundholding practices, fundholders increasi ngly prescribed less expensive medicines (cimetidine and nizatidine) within the class of histamine(2) receptor antagonists. However, fundholders adopt ed proton pump inhibitors or selective serotonin re-uptake inhibitors at th e same rate as non-fundholders. Conclusion. Fundholders have used therapeutic substitution with medicines o f equal effectiveness to contain prescribing costs. There is no evidence th at fundholders have been slower than non-fundholders to use newer, more exp ensive medicines.