Weaning physicians to generic antibiotics
QI team makes it easy to do the right thing’
Physicians know that generic drugs are as good as brand names most of the time. But what they didn’t know at Group Health Associates’ (GHA) Clifton facility in Cincinnati is that generics cost five to 10 times less than brand names. GHA internist and infectious disease specialist Huxley Miller, MD, explains that supplying that piece of data was critical to the clinic’s smooth transition to a generics-first practice. "And, we used the principle of making it easy for people to do the right thing."
The prescribing practices initiative started three years ago in the pediatrics department of this 105-physician multispecialty group. Today, their total pharmaceutical costs run 15% less than their peers in the area.
Identifying holes in pharmaceutical care
The baseline 40-chart sample showed a pattern of prescribing Biaxin as a first-line antibiotic for strep or otitis media when clinical evidence shows that generic amoxicillin does just as well. According to GHA figures, the selling prices of the two drugs are $35 compared to $6.75 for a 10-day supply.
Chart samples also turned up plenty of evidence that adults were receiving antibiotics for bronchitis, a viral problem that doesn’t respond to antibiotics at all. "Most doctors understand that all of us write more antibiotic prescriptions than we need, so it didn’t take a lot of arm-twisting to get them on board for more appropriate pharmaceutical practices," notes Barry Malinowski, MD, pediatrician and medical director at GHA.
It helped that physicians on the QI team didn’t hold up their prescribing practices as exemplary. Miller admits that while his antibiotics record looked clean, "I didn’t look so good on migraine drugs."
Action plan rich with information
The interdisciplinary QI team conducts informal "academic detailing" for the physicians and pharmacists at GHA’s various clinics. Team members, who also include GHA’s Steve Bird, MD, a pediatrician; Dave Hoffman, a pharmacy director; and Renate Thomas, MD, an internist, apprise their colleagues on clinical studies of the latest prescription drugs. Most memos from the team have supportive articles attached.
Other ways in which the team makes it easy for the doctors to stick to prescription initiatives are:
1. Prescription guidelines are posted in each doctor’s office.
Listings lay out first-, second- and third-line drugs for otitis media, strep, gastric problems, and migraine headaches.
2. Drug closets are stocked with generic samples instead of brand names.
For instance, Miller explains, patients with a possible strep throat start with a two-day course of generic antibiotics. If their lab results are positive, they get a prescription for the same med.
3. Thomas wrote a patient handout, "Why antibiotics aren’t the answer for all ailments," which the doctors provide in cases of flu, sore throat, and other respiratory problems.
That, along with the local HMOs’ co-pay system in which brand-name drugs cost more than generics, motivates patients toward appropriate medication decisions. In fact, many consumers ask doctors if a generic would do as well as a brand-name drug. (See a copy of the handout, p. 35.)
However, there are those who demand antibiotics even when they aren’t indicated. "But if we take the time to explain the difference between viruses and bacteria, a lot of those patients and families will understand why we can’t help them with a prescription," Malinowski says.
Progress notes and further plans
Two years into the initiative, GHA has a handle on managing its drug use. Its overall antibiotic use is down, and the dispensing of first-line generic antibiotics netted a $120,000 annual savings. (For details, see IHI graph and percentages comparison, at left.)
But the project isn’t over yet:
• Pharmacies at each of the ambulatory clinics regularly provide the physicians with individual and group prescription profiles.
• The team is closing what they see as a serious information gap. "We can go to Walgreen’s and get the price of a box of Band-Aids, but as a doctor, you can’t [readily] find out the prices of the drugs you prescribe," Miller contends. Which doesn’t help as the doctor prescribes a generic equivalent for the brand-name drug a patient saw advertised on television. But soon, GHA prescription pads will have price lists of the commonly used drugs. "Then, we’ll know whether a pill costs two cents or a dollar."
The QI team holds hour-long weekly phone conferences to review new drugs and prepare updates for their colleagues on the latest research. The team maintains that in an environment of appropriate prescription drug use, there’s room in the budget for isolated use of expensive drugs. What kills the budget is the regular use when less costly equivalents would do just as well. GHA participated in the Boston-based Institute for Healthcare Improvement’s Improving Prescribing Practices Breakthrough Series.
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