Canadian Medical Association Journal 1996; 154: 675-677
Improving prescribing practices is crucial: it represents the clearest available opportunity to improve disease management without putting additional pressure on hospital or ambulatory services. Although we have been led to see prescribing issues mainly from the perspective of cost containment, the question of quality assurance is equally important. There is every reason to believe that the optimal use of medications will result in lower or unchanged health care spending, but this does not necessarily mean that total drug costs will be reduced. We have been persuaded by governments and, to some extent, private insurers to regard drug prescribing as a drain on health care resources -- without due regard to the curative and preventive benefits of drug therapy and the sometimes pressing need for more, not less, pharmacologic treatment. Physicians should rally to the cause of improved drug prescribing, not because of potential savings but because of the essential improvements to be made in patient care and health outcomes. Furthermore, the reallocation of resources toward quality in drug prescribing would foster a chain reaction of education and research initiatives, the benefits of which would be felt throughout the profession. It is important that the goal of improved care not be obscured by an obsession with cost containment that ignores equally important health goals.
Canadians have been bombarded with reports of strategies to improve the use of prescription drugs and streamline regulation, reimbursement and the dissemination of prescribing information.[1] The result has been a classic case of paralysis by analysis, culminating in the ill-fated National Pharmaceutical Strategy, which was discussed during the past 3 years. This initiative was finally brought to a standstill in 1995 by the apparent lack of interest on the part of provincial deputy health ministers in nonfiscal aspects of drug prescribing.
Although public servants who steer provincial drug plans agree that physicians require more information in order to improve prescribing, they have not recognized the need to invest in research and education to assure the timely delivery of such information. The issues addressed in the National Pharmaceutical Strategy were the same as those taken up at the CMA workshop, but the need for the provision of information to support optimal prescribing has in the interim become more pressing. Provincial governments are now withdrawing from their programs that support the provision of therapeutic drugs because of their unwillingness to maintain previous levels of payment. The federal government has never been credible in this area because drug therapy is not covered by the terms of the Canada Health Act. The federal influence on drug prescribing has been restricted to drug regulation, an area in which the government has found it difficult to please all stakeholders. In this leadership vacuum the field remains open to physicians who, acting in accord with the highest standards of professionalism, have the opportunity to develop a framework to assure optimal prescribing practices that rest on a foundation of sound information and continuing education.
Physicians have been accused of failing to rely on evidence in the application of diagnostic and therapeutic techniques. Although this premise is debatable, the recognition that choices based on evidence are to be preferred has given rise to a new movement in practice[2] and now has journals devoted to it such as Evidence-Based Medicine.[3] However, controversy remains on the extent of the problem.[4,5] An optimistic view is that physicians are already adept at applying evidence in therapeutics, once that evidence has been amassed and effectively communicated. None the less, there are clearly areas of significant underprescribing, as in the treatment of hypertension, myocardial infarction and depression. Significant overprescribing probably occurs in the treatment of disorders such as anxiety, insomnia, viral infection and lassitude. The variability in drug prescribing that Anis and associates discuss in this issue speaks to a lack of consensus in the management of many common conditions. Of course, such shortcomings can be corrected, although total homogeneity in prescribing is neither desirable nor achievable. Improved access to evidence to support clinical decision making and the electronic dissemination of information as part of "just-in-time education" will go a long way to improving prescribing practices.[1,6]
Other strategies adopted elsewhere have had a mixed impact. In the United Kingdom direct feedback to practitioners about their prescribing profiles drove patterns toward the norm;[7] this is generally recognized as an improvement in overall drug use. In Germany insurers allotted fixed amounts to cover the cost of prescriptions. Any overspending on drugs was to be taken out of the funds available as compensation for physician services. Practitioners responded by altering their prescribing practices; by June 1993, 6 months after the new policy was implemented, drug expenditures were 16.2% below the June 1992 level.[8] This dramatic change may seem desirable, but it is worrisome in contexts where underprescribing is common. In the United States Medicare and Medicaid plans have used the expedient of delisting drug benefits in some states, but results have proved unpredictable and the savings illusory.[9] The conclusion is inescapable that the policy knife as wielded to date is not a very fine instrument, although this fact is not fully appreciated by policymakers. Several examples of the eviceration of drug plans with blunt instruments are now apparent in Canada:
The low-hanging fruit is poised tantalizingly near. It can be seized by physicians acting alone, but it would be preferable for prescribers to take the lead in a multisectoral effort that recognizes the interests of insurers, employers and, above all, patients.[10] Furthermore, the partnership of drug manufacturers should be seen as an essential asset rather than an obstacle to progress. The CMA deserves commendation for organizing a workshop on physician prescribing practices that has led to the publication of seminal papers. This is a good beginning, but the next steps require and deserve the support of the entire profession.