Objective. - To lower nonsteroidal anti-inflammatory drug (NSAID) costs while maintaining quality patient care and clinician satisfaction. Design. - Before and after 21 -month trial with one study site and two control 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 requiring a trial of either ibuprofen or indomethacin before new prescription of more expensive NSAIDs. One control center used an NSAID computer cost-prompt and the other had no intervention. Main Outcome Measures. - The proportion of expensive NSAIDs prescribed at each institution and total NSAID costs adjusted for prescription volume. Clinician acceptance and patient impact were assessed by the questionnaire. Results. - Study site clinicians (n=158) reported very few protocol-related patient care 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 21%, decreasing costs by 30% (P<.001). In contrast, the site with a computer cost-prompt had only a 5% decrease in NSAID costs, while costs at the site with no intervention increased 2%. Conclusions. - For drugs with similar benefits and adverse effects, a 'stepped formulary' approach requiring an initial trial of one of the less expensive agents can maintain physician prescribing choices and satisfaction while lowering costs.
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