Drug prescribing is one of the armamentarium in a physician’s tool box to help manage disease and alleviate suffering. However, the risks of certain drugs in particular clinical contexts outweigh the benefits and may lead to preventable drug-related morbidity and mortality. Such high-risk prescribing is a common concern.
What is the safer prescribing trial about?
In this week’s issue of NEJM, Dreischulte and colleagues asked whether a 48-week intervention consisting of clinician education outreach, financial incentive, and clinician reviewing patient information can reduce high-risk prescribing of NSAIDs and anti-platelet therapy. The intervention is part of a data-drive program in which the primary care physicians are: 1) educated about the risks of NSAIDs and anti-platelet medications; 2) given access to a web-based tool that identifies patients at highest risk for adverse drug events associated with NSAIDs and anti-platelet medications; and 3) given financial incentives to review information about these high-risk patients ($600 fixed participation fee per practice and $25 per patient information reviewed).
The investigators randomized 34 primary care practices in Scotland with over 202,000 patients to different start dates of the intervention. The primary outcome was the percentage of patients at high risk for one of the three adverse drug events (gastrointestinal bleeding, renal failure, and heart failure) associated with use of NSAIDs and anti-platelet therapy who were currently prescribed such medication. Secondary outcomes included ongoing (prescribed within the past year) and new (not prescribed within the past year) high-risk prescription rates and emergency hospital admissions associated with one of the three adverse drug events of gastrointestinal bleeding, renal failure, and heart failure.
What did the study show?
The analysis included over 33,000 patients with risk factors for adverse drug events using NSAIDs and anti-platelet therapy. For the primary outcome, there was a reduction in the percentage of patients prescribed high-risk NSAIDs and anti-platelet therapies during the intervention compared with prior to the intervention (2.2% versus 3.7%; adjusted OR 0.63, 95%CI 0.57-0.68, p<0.001).
There were significant reductions in the rates of ongoing and new high-risk prescribing (adjusted ORs 0.60 and 0.77, respectively). Emergent hospitalization rates related to gastrointestinal bleeding and acute kidney injury associated with recent high-risk prescriptions were also significantly reduced (RR 0.09 and RR 0.32, respectively). However, the reduction in admission rates for heart failure associated with recent NSAIDs prescription was not significant (RR 0.54, 95%CI 0.20-1.51).
Post-hoc analysis determined the reduction of high-risk prescribing was sustained in the 48-week period after the end of the intervention when financial incentive stopped (adjusted OR 1.14, 95%CI 0.85-1.53, p=0.38).
So what are the caveats?
From this study we learned that a complex intervention consisting of clinician education, informatics to identify high-risk patients, and a financial incentive in the primary care setting can modify physicians’ prescribing behavior and reduce high-risk prescribing. The study, however, does not provide us with information about which component of this complex intervention matters the most and whether it can be effective by itself. Additionally, it is unclear whether a different type of approach is required for modifying prescribing behavior in other disease condition and drug treatments.
What factors do you think affect a physician’s prescribing behavior?
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James was a 2015-2016 NEJM Editorial Fellow. He recently completed fellowship in General Internal Medicine at Brigham and Women’s Hospital. He is interested in evidence-based medicine, medical education, knowledge translation, and pharmacoepidemiology.