Optimizing Drug Prescribing in Managed Care Populations: Improving Clinical and Economic Outcomes

Managed care presents interesting opportunities to optimize clinical and economic outcomes related to drug prescribing. There are very few randomized controlled trials that have evaluated methods to educate or incentivize physicians, implement formulary management or guideline tools, profile physicians, and implement pharmacist interventions to ensure optimal drug prescribing. Single methods of optimizing medication outcomes have not been shown to be as effective as multifaceted approaches. Specific reinforcement of the message at the time of prescribing has been shown to improve antibiotic prescribing in patients with chronic bronchitis and improve adherence to treatment guidelines for the management of patients following myocardial infarction. Results from a randomized controlled trial showed that changes in pharmacy benefit design decreased costs and medication utilization. Much of the literature evaluating the effectiveness of utilization management techniques in optimizing drug therapy outcomes is retrospective in nature. However, pharmacist intervention has been shown to reduce polypharmacy in a randomized controlled trial in the elderly. Appropriate prescribing scores were improved and this improvement was sustained at 12 months post intervention. Clinical pharmacy services have been shown to reduce hospital admission and hospital days, decrease prescription and total health care costs, reduce the number of drugs per patient, and improve attainment of target low density lipoprotein cholesterol values. Recent analyses have shown that there is a higher likelihood of achieving improved outcomes of care when three or more of the following aspects of healthcare are impacted: patient self-management, clinical information availability, redesign of the way care is delivered, decision support strategies, the healthcare system, and the provider organization. In a review of interventions designed to improve the care of patients with chronic illnesses, process variables were improved when one or two of the aspects were improved. Outcome variables were improved when three or four of the aspects were impacted. There continues to be great focus on improving the quality of care in managed care environments. With the passing of the Medicare legislation in the US, by 2006 the vast majority of citizens will receive healthcare in managed care environments. Additional research designed to explore methods of optimizing drug therapy outcomes is needed to characterize the most efficient, transparent, and least costly ways to reduce misuse, overuse, and underuse of prescription drugs.