Rational Prescribing in Primary Care (RaPP): Economic Evaluation of an Intervention to Improve Professional Practice

PLoS Medicine, Jun 2006

Background Interventions designed to narrow the gap between research findings and clinical practice may be effective, but also costly. Economic evaluations are necessary to judge whether such interventions are worth the effort. We have evaluated the economic effects of a tailored intervention to support the implementation of guidelines for the use of antihypertensive and cholesterol-lowering drugs. The tailored intervention was evaluated in a randomized trial, and was shown to significantly increase the use of thiazides for patients started on antihypertensive medication, but had little or no impact on other outcomes. The increased use of thiazides was not expected to have an impact on health outcomes. Methods and Findings We performed cost-minimization and cost-effectiveness analyses on data from a randomized trial involving 146 general practices from two geographical areas in Norway. Each practice was randomized to either the tailored intervention (70 practices; 257 physicians) or control group (69 practices; 244 physicians). Only patients that were being started on antihypertensive medication were included in the analyses. A multifaceted intervention was tailored to address identified barriers to change. Key components were an educational outreach visit with audit and feedback, and computerized reminders. Pharmacists conducted the visits. A cost-minimization framework was adopted, where the costs of intervention were set against the reduced treatment costs (principally due to increased use of thiazides rather than more expensive medication). The cost-effectiveness of the intervention was estimated as the cost per additional patient being started on thiazides. The net annual cost (cost minimization) in our study population was US$53,395, corresponding to US$763 per practice. The cost per additional patient started on thiazides (cost-effectiveness) was US$454. The net annual savings in a national program was modeled to be US$761,998, or US$540 per practice after 2 y. In this scenario the savings exceeded the costs in all but two of the sensitivity analyses we conducted, and the cost-effectiveness was estimated to be US$183. Conclusions We found a significant shift in prescribing of antihypertensive drugs towards the use of thiazides in our trial. A major reason to promote the use of thiazides is their lower price compared to other drugs. The cost of the intervention was more than twice the savings within the time frame of our study. However, we predict modest savings over a 2-y period.

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Rational Prescribing in Primary Care (RaPP): Economic Evaluation of an Intervention to Improve Professional Practice

Oxman AD (2006) Rational Prescribing in Primary Care (RaPP): Economic evaluation of an intervention to improve professional practice. PLoS Med 3(6): e216. DOI: 10.1371/journal.pmed.0030216 Rational Prescribing in Primary Care (RaPP): Economic Evaluation of an Intervention to Improve Professional Practice Atle Fretheim 0 1 Morten Aaserud 0 1 Andrew D. Oxman 0 1 Steve Jan, George Institute for International Health, United States of America 0 Funding: The study was funded by the Norwegian Ministry of Health, the Norwegian Directorate for Health and Social Affairs, and the Norwegian Knowledge Centre for Health Services. The funding agencies had no influence on the design or conduct of the study 1 Norwegian Knowledge Centre for Health Services , Oslo , Norway A B S T R A C T Interventions designed to narrow the gap between research findings and clinical practice may be effective, but also costly. Economic evaluations are necessary to judge whether such interventions are worth the effort. We have evaluated the economic effects of a tailored intervention to support the implementation of guidelines for the use of antihypertensive and cholesterol-lowering drugs. The tailored intervention was evaluated in a randomized trial, and was shown to significantly increase the use of thiazides for patients started on antihypertensive medication, but had little or no impact on other outcomes. The increased use of thiazides was not expected to have an impact on health outcomes. - We found a significant shift in prescribing of antihypertensive drugs towards the use of thiazides in our trial. A major reason to promote the use of thiazides is their lower price compared to other drugs. The cost of the intervention was more than twice the savings within the time frame of our study. However, we predict modest savings over a 2-y period. The Editors Summary of this article follows the references. Introduction Implementing high-quality clinical practice guidelines may be a way of improving clinical practice. However, the effect of implementation strategies is usually modest, and more effective interventions, such as educational outreach visits, tend to be more costly [1]. There are numerous trials of quality improvement strategies, but comprehensive cost benefit or cost-effectiveness analyses are scarce. The authors of a recent systematic review of guideline implementation strategies found that relatively few studies considered any costs other than those of treatment and its consequences [2]. We have conducted a rigorous evaluation of a tailored intervention designed to improve prescribing of antihypertensive and cholesterol-lowering drugs in primary practice (Figure 1) [3]. The intervention was multifaceted, and included (1) an educational outreach visit to clinics, during which guidelines were presented and discussed, (2) an audit and feedback on current adherence to guidelines and recommendations, and (3) a system providing computerized reminders to the physicians during patient consultations. The effectiveness of this multifaceted intervention was evaluated in a randomized controlled trial, in which the control intervention was passive dissemination of guidelines through a national medical journal [3]. The main outcomes analyzed in the trial were the following: (1) the proportion of prescriptions of thiazide-type diuretics to patients being prescribed antihypertensive drugs for the first time, for primary prevention of cardiovascular disease, (2) the proportion of patients for whom the level of cardiovascular risk had been estimated among all those started on antihypertensive or cholesterol-lowering treatment for primary prevention, and (3) the proportion of patients with a recorded level of cholesterol (total or low-density lipoprotein) or blood pressure satisfying the specified treatment goals among all patients on the corresponding treatment for at least 3 mo. For cholesterol we decided to also include patients on secondary prevention therapy since the treatment goals are similar. The intervention resulted in increased prescribing of thiazides, but no significant changes in the two other main outcomes. With regards to health outcomes, the choice of antihypertensive drug has limited impact [4,5], and was disregarded in our analyses. Consequently, the primary question was whether the savings on drug costs were greater than the costs of the intervention, given that the cost of thiazides is much lower than that of other antihypertensive drugs. Thus, we conducted a cost-minimization analysis comparing costs and effects of two strategies: (1) our multifaceted intervention and (2) usual care. We were also interested in knowing the costs incurred relative to the achieved changes in clinical practice, a form of costeffectiveness analysis. Data collection for the economic analysis was planned before the trial was conducted. The study protocol is available via the Norwegian Knowledge Centre for Health Services Web site [6] and as (...truncated)


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Atle Fretheim, Morten Aaserud, Andrew D Oxman. Rational Prescribing in Primary Care (RaPP): Economic Evaluation of an Intervention to Improve Professional Practice, PLoS Medicine, 2006, Volume 3, Issue 6, DOI: 10.1371/journal.pmed.0030216